Provider Demographics
NPI:1790736189
Name:THAYER, PENNY R (FNP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:R
Last Name:THAYER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ROSEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-2931
Mailing Address - Country:US
Mailing Address - Phone:423-979-3497
Mailing Address - Fax:
Practice Address - Street 1:SIDNEY AND LAMONT
Practice Address - Street 2:BUILGING 69
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684
Practice Address - Country:US
Practice Address - Phone:423-979-3497
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000006700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner