Provider Demographics
NPI:1376832261
Name:PENDER, CIANNA
Entity Type:Individual
Prefix:
First Name:CIANNA
Middle Name:
Last Name:PENDER
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 1:100 MIMOSA DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6676
Mailing Address - Country:US
Mailing Address - Phone:229-226-8881
Mailing Address - Fax:229-584-5964
Practice Address - Street 1:100 MIMOSA DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6676
Practice Address - Country:US
Practice Address - Phone:229-226-8881
Practice Address - Fax:229-584-5964
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA76648208600000X
LAPGY.201257208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2151193Medicaid