MEDICARE: MISS ASHLEY NICOLA PENDERGRAST

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

General Provider Information

NPI Number	:	1568093854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ASHLEY NICOLA PENDERGRAST

Provider Business Mailing Address
First Line	:	7318 MONSEY CIR APT 102
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-8356
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7318 MONSEY CIR APT 102
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-8356
Country	:	US
Telephone Number	:	502-435-2528
Fax Number	:

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

Provider Enumeration Date	:	01/27/2020
Last Update Date	:	01/27/2020

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Directions to “ MISS ASHLEY NICOLA PENDERGRAST ” Practice Location

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