Provider Demographics
NPI:1700421864
Name:PEMBERTON, CAITLIN MARY
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARY
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6985 SPRINGCREST CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-1075
Mailing Address - Country:US
Mailing Address - Phone:810-691-2239
Mailing Address - Fax:
Practice Address - Street 1:303 E KEARSLEY ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-1907
Practice Address - Country:US
Practice Address - Phone:810-762-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704351620367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty