Healthcare Provider Details

I. General information

NPI: 1881916831
Provider Name (Legal Business Name): LANIS PENDLETON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 GILMORE AVE
LAKELAND FL
33805-3017
US

IV. Provider business mailing address

PO BOX 1559
BARTOW FL
33831-1559
US

V. Phone/Fax

Practice location:
  • Phone: 863-519-0575
  • Fax: 863-582-9251
Mailing address:
  • Phone: 863-519-0575
  • Fax: 863-582-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN483442
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: