Provider Demographics
NPI:1053631028
Name:PENDARVIS, COLLETTE (BA)
Entity Type:Individual
Prefix:MISS
First Name:COLLETTE
Middle Name:
Last Name:PENDARVIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005-0163
Mailing Address - Country:US
Mailing Address - Phone:405-413-2118
Mailing Address - Fax:
Practice Address - Street 1:510 E KANSAS AVE
Practice Address - Street 2:
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005-2641
Practice Address - Country:US
Practice Address - Phone:405-413-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator