Provider Demographics
NPI:1497187629
Name:POPE, PENNY MOONEY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:MOONEY
Last Name:POPE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:MOONEY
Other - Last Name:POPE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:172 W INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-3566
Mailing Address - Country:US
Mailing Address - Phone:336-415-5851
Mailing Address - Fax:336-415-5854
Practice Address - Street 1:172 W INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3566
Practice Address - Country:US
Practice Address - Phone:336-415-5851
Practice Address - Fax:336-415-5854
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006312363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1124486832Medicaid
NCF825Medicare PIN