Provider Demographics
NPI:1447588488
Name:PANDEYA, JACKIE A (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:A
Last Name:PANDEYA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:A
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-780-2497
Mailing Address - Fax:270-783-0454
Practice Address - Street 1:950 MAIN ST.
Practice Address - Street 2:
Practice Address - City:MUNFORDVILLE
Practice Address - State:KY
Practice Address - Zip Code:42765
Practice Address - Country:US
Practice Address - Phone:270-524-1201
Practice Address - Fax:270-506-5972
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-13005363LF0000X
KY3006282363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily