Provider Demographics
NPI:1811088685
Name:PENNELLI, KAREN M (PA)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:M
Last Name:PENNELLI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3400 OLD MILTON PKWY # C
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-3707
Mailing Address - Country:US
Mailing Address - Phone:770-667-4337
Mailing Address - Fax:770-667-4338
Practice Address - Street 1:470 NORTHSIDE CHEROKEE BLVD STE 170
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8029
Practice Address - Country:US
Practice Address - Phone:770-721-9540
Practice Address - Fax:770-721-9541
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA784363A00000X
MAPA784363AS0400X
GA008027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS63003Medicare UPIN
MAAP0897Medicare PIN
MAAP089701Medicare PIN