Provider Demographics
NPI:1407101793
Name:PENDERGAST, KATLYNN RENEA
Entity Type:Individual
Prefix:
First Name:KATLYNN
Middle Name:RENEA
Last Name:PENDERGAST
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:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:503-552-6208
Practice Address - Street 1:29197 SW ORLEANS AVE
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-7388
Practice Address - Country:US
Practice Address - Phone:503-427-0182
Practice Address - Fax:503-427-0228
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator