Basic Information
| Provider Information | |||||||||
| NPI: | 1801448246 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENDRY | ||||||||
| FirstName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 BREWSTER BLVD | ||||||||
| Address2: | |||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285472575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104504300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 BREWSTER BLVD | ||||||||
| Address2: | |||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285472575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104504300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2019 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | 209019713 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.