MEDICARE: KENYATTA PUGH

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	374U00000X	Home Health Aide	170003871	TN

General Provider Information

NPI Number	:	1215543251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYATTA PUGH

Provider Business Mailing Address
First Line	:	1176 VICKERY LN STE 200
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38016-0631
Country	:	US
Telephone Number	:	901-255-4490
Fax Number	:	901-416-4490

Provider Business Practice Location Address
First Line	:	1176 VICKERY LN STE 200
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38016-0631
Country	:	US
Telephone Number	:	901-255-4490
Fax Number	:	901-416-4490

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

Provider Enumeration Date	:	09/16/2020
Last Update Date	:	09/16/2020

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Directions to “ KENYATTA PUGH ” Practice Location

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