Provider Demographics
NPI:1952483588
Name:PENDERGRASS, KATHY M (PHD, CFNP)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:M
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:PHD, CFNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3724
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39303-3724
Mailing Address - Country:US
Mailing Address - Phone:601-286-5551
Mailing Address - Fax:601-286-5548
Practice Address - Street 1:4707 POPLAR SPRINGS DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-2622
Practice Address - Country:US
Practice Address - Phone:601-286-5551
Practice Address - Fax:601-286-5548
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR801465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q58952Medicare UPIN