Provider Demographics
NPI:1548527344
Name:PEGRAM, NINA E (PNP)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:E
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 GRAHAM RD W
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1055
Mailing Address - Country:US
Mailing Address - Phone:607-257-2188
Mailing Address - Fax:607-266-7341
Practice Address - Street 1:10 GRAHAM RD W
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1055
Practice Address - Country:US
Practice Address - Phone:607-257-2188
Practice Address - Fax:607-266-7341
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-56399174N00000X
NY382280363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No174N00000XOther Service ProvidersLactation Consultant, Non-RN