Provider Demographics
NPI:1740758184
Name:PENROD, KATHLEEN (APRN FNP-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PENROD
Suffix:
Gender:F
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 GUNSON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37050-4377
Mailing Address - Country:US
Mailing Address - Phone:931-627-1366
Mailing Address - Fax:
Practice Address - Street 1:407 GUNSON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND CITY
Practice Address - State:TN
Practice Address - Zip Code:37050-4377
Practice Address - Country:US
Practice Address - Phone:931-627-1366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-04
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000025042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily