Provider Demographics
NPI:1093012064
Name:PONDER, JANETTA SHANTE
Entity Type:Individual
Prefix:
First Name:JANETTA
Middle Name:SHANTE
Last Name:PONDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:153 MELROSE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1803
Practice Address - Country:US
Practice Address - Phone:585-284-6645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-27
Last Update Date:2011-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302685164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse