Provider Demographics
NPI:1801858949
Name:NETTLES-PEGRAM, PATRICIA D (SOCIAL WORKER)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:D
Last Name:NETTLES-PEGRAM
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PIRATES CV
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-5224
Mailing Address - Country:US
Mailing Address - Phone:757-850-4722
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040015811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical