Provider Demographics
NPI:1649315888
Name:PENDERGRASS, CONNIE (MHS, RPT)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:MHS, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:AR
Mailing Address - Zip Code:72422-1903
Mailing Address - Country:US
Mailing Address - Phone:870-857-0049
Mailing Address - Fax:870-857-3027
Practice Address - Street 1:1700 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:AR
Practice Address - Zip Code:72422-1903
Practice Address - Country:US
Practice Address - Phone:870-857-0049
Practice Address - Fax:870-857-3027
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S640OtherBCBS
AR5S640C262Medicare ID - Type Unspecified