Provider Demographics
NPI:1336864198
Name:PENDRAGON, AMANDA NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:PENDRAGON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:157 TOWNE DR STE 103
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8460
Practice Address - Country:US
Practice Address - Phone:270-765-5926
Practice Address - Fax:270-763-0051
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3018433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily