Provider Demographics
NPI:1265425797
Name:CHAMPION, PENNY L (CNM)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:L
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:L
Other - Last Name:BOZEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:414 FIFTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701
Mailing Address - Country:US
Mailing Address - Phone:229-883-4555
Mailing Address - Fax:229-888-0063
Practice Address - Street 1:414 5TH AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1976
Practice Address - Country:US
Practice Address - Phone:229-883-4555
Practice Address - Fax:229-888-0063
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR079412367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00787146AMedicaid
GA42BBBHWMedicare ID - Type Unspecified
GA00787146AMedicaid