Provider Demographics
NPI:1508325242
Name:PENDERGRASS, YASHATE KINKIA (RN)
Entity Type:Individual
Prefix:
First Name:YASHATE
Middle Name:KINKIA
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:YASHATE
Other - Middle Name:KINKIA
Other - Last Name:PENDERGRASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:YASHATE K MANNING
Mailing Address - Street 1:2159 GROVE LANDING WAY
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-7017
Mailing Address - Country:US
Mailing Address - Phone:843-356-3374
Mailing Address - Fax:
Practice Address - Street 1:2159 GROVE LANDING WAY
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-7017
Practice Address - Country:US
Practice Address - Phone:843-356-3374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC107470163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health