Healthcare Provider Details

I. General information

NPI: 1053640698
Provider Name (Legal Business Name): MICHAEL L PENDLETON SR. APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 N RACE ST
GLASGOW KY
42141-3473
US

IV. Provider business mailing address

PO BOX 906
GLASGOW KY
42142-0906
US

V. Phone/Fax

Practice location:
  • Phone: 270-629-6333
  • Fax: 270-629-6334
Mailing address:
  • Phone: 270-678-6333
  • Fax: 270-678-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6291P
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: