Provider Demographics
NPI:1225257819
Name:PENDERGRASS, DANIELLE HOWA (DNP, APRN, WHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:HOWA
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:DNP, APRN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 S 600 E
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-3174
Mailing Address - Country:US
Mailing Address - Phone:435-637-0313
Mailing Address - Fax:435-637-0317
Practice Address - Street 1:77 S 600 E
Practice Address - Street 2:SUITE B
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-3174
Practice Address - Country:US
Practice Address - Phone:435-637-0313
Practice Address - Fax:435-637-0317
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT319637-4405363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1225257819Medicaid
UTU000078450Medicare PIN