Provider Demographics
NPI:1639561160
Name:PENDERGRASS, JOY SUSAN (FNP,BC)
Entity Type:Individual
Prefix:MRS
First Name:JOY
Middle Name:SUSAN
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 1:536 SPANISH WAY W
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-9244
Mailing Address - Country:US
Mailing Address - Phone:904-310-9468
Mailing Address - Fax:
Practice Address - Street 1:536 SPANISH WAY W
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-9244
Practice Address - Country:US
Practice Address - Phone:904-310-9468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9364981363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily