MEDICARE: DR. KATHY M. PENDERGRASS PHD, CFNP

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	R801465	MS

General Provider Information

NPI Number	:	1952483588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHY M. PENDERGRASS PHD, CFNP

Provider Business Mailing Address
First Line	:	PO BOX 3724
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39303-3724
Country	:	US
Telephone Number	:	601-286-5551
Fax Number	:	601-286-5548

Provider Business Practice Location Address
First Line	:	4707 POPLAR SPRINGS DR
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39305-2622
Country	:	US
Telephone Number	:	601-286-5551
Fax Number	:	601-286-5548

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	02/25/2016

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