Provider Demographics
NPI:1518522283
Name:PENDERGRASS, BRIANNA MICHELLE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:MICHELLE
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 VILLA WAY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-6106
Mailing Address - Country:US
Mailing Address - Phone:601-720-7166
Mailing Address - Fax:
Practice Address - Street 1:1325 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2442
Practice Address - Country:US
Practice Address - Phone:601-354-4488
Practice Address - Fax:601-351-5980
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904177207Q00000X, 363LF0000X
TN25671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine