Provider Demographics
NPI:1649846304
Name:PENDERGRASS, MIKKA MICHELE (AGACNP)
Entity type:Individual
Prefix:
First Name:MIKKA
Middle Name:MICHELE
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 S 400 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2515
Mailing Address - Country:US
Mailing Address - Phone:801-901-7688
Mailing Address - Fax:
Practice Address - Street 1:1950 CIRCLE OF HOPE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5500
Practice Address - Country:US
Practice Address - Phone:801-581-2436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT86680593102363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care