MEDICARE: MR. MICHAEL L PENDLETON SR. APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	6291P	KY

General Provider Information

NPI Number	:	1053640698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL L PENDLETON SR. APRN

Provider Business Mailing Address
First Line	:	PO BOX 906
Second Line	:
City	:	GLASGOW
State	:	KY
Zip	:	42142-0906
Country	:	US
Telephone Number	:	270-678-6333
Fax Number	:	270-678-7333

Provider Business Practice Location Address
First Line	:	1412 N RACE ST
Second Line	:
City	:	GLASGOW
State	:	KY
Zip	:	42141-3473
Country	:	US
Telephone Number	:	270-629-6333
Fax Number	:	270-629-6334

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2009
Last Update Date	:	10/09/2023

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