Provider Demographics
NPI:1295281236
Name:PEMBERTON, ELIZABETH (AGNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 HARBOUR POINTE DR
Mailing Address - Street 2:
Mailing Address - City:GROVER
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1937
Mailing Address - Country:US
Mailing Address - Phone:314-308-5424
Mailing Address - Fax:
Practice Address - Street 1:306 HARBOUR POINTE DR
Practice Address - Street 2:
Practice Address - City:GROVER
Practice Address - State:MO
Practice Address - Zip Code:63040-1937
Practice Address - Country:US
Practice Address - Phone:314-308-5424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016012215363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health