Provider Demographics
NPI:1710078423
Name:BOOTH, PENNY D (CFNP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:D
Last Name:BOOTH
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 18TH ST E STE 400
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3684
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:
Practice Address - Street 1:901 18TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3648
Practice Address - Country:US
Practice Address - Phone:229-382-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN202921363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000270634Medicaid
WV3810004243Medicaid
OH2933277Medicaid
WV3810004243Medicaid
WVBONP19192Medicare PIN
WVQ52982Medicare UPIN
WVP00687536Medicare PIN