Basic Information
Provider Information | |||||||||
NPI: | 1548527344 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEGRAM | ||||||||
FirstName: | NINA | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10 GRAHAM RD W | ||||||||
Address2: |   | ||||||||
City: | ITHACA | ||||||||
State: | NY | ||||||||
PostalCode: | 148501055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6072572188 | ||||||||
FaxNumber: | 6072667341 | ||||||||
Practice Location | |||||||||
Address1: | 10 GRAHAM RD W | ||||||||
Address2: |   | ||||||||
City: | ITHACA | ||||||||
State: | NY | ||||||||
PostalCode: | 148501055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6072572188 | ||||||||
FaxNumber: | 6072667341 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2012 | ||||||||
LastUpdateDate: | 05/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174N00000X | L-56399 |   | N |   | Other Service Providers | Lactation Consultant, Non-RN |   | 363LP0200X | 382280 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.