Provider Demographics
NPI:1578156782
Name:PENDLETON, DIANNA MARIE (FNP)
Entity Type:Individual
Prefix:MS
First Name:DIANNA
Middle Name:MARIE
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:FNP
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 1619
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043-1619
Mailing Address - Country:US
Mailing Address - Phone:828-247-0366
Mailing Address - Fax:828-247-1870
Practice Address - Street 1:331 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-3648
Practice Address - Country:US
Practice Address - Phone:828-247-0366
Practice Address - Fax:828-247-1870
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC126357363LF0000X
NC5014193363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1487244943Medicaid