Healthcare Provider Details

I. General information

NPI: 1518522283
Provider Name (Legal Business Name): BRIANNA MICHELLE PENDERGRASS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

IV. Provider business mailing address

110 VILLA WAY
CLINTON MS
39056-6106
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4488
  • Fax: 601-351-5980
Mailing address:
  • Phone: 601-720-7166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number904177
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25671
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904177
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: