Provider Demographics
NPI:1568948016
Name:PONDER, COURTNEY LEIGH (APRN)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEIGH
Last Name:PONDER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LEIGH
Other - Last Name:COATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11516 LAMEY BRIDGE RD STE I
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-2725
Mailing Address - Country:US
Mailing Address - Phone:228-207-4190
Mailing Address - Fax:
Practice Address - Street 1:11516 LAMEY BRIDGE RD STE I
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540
Practice Address - Country:US
Practice Address - Phone:228-207-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily