Provider Demographics
NPI:1669810529
Name:PENDLETON, HENRY RANDALL JR (NP)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:RANDALL
Last Name:PENDLETON
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 STANIFORD ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3105
Mailing Address - Country:US
Mailing Address - Phone:401-421-8800
Mailing Address - Fax:401-273-6510
Practice Address - Street 1:1407 S COUNTY TRL
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1652
Practice Address - Country:US
Practice Address - Phone:401-886-4040
Practice Address - Fax:401-886-4010
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP37741363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health