Provider Demographics
NPI:1194273292
Name:PENDERGRASS, BRANDY SHARESE
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:SHARESE
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 SOUTHERN BLVD
Mailing Address - Street 2:APT. 810
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-4604
Mailing Address - Country:US
Mailing Address - Phone:347-824-9664
Mailing Address - Fax:
Practice Address - Street 1:9777 QUEENS BLVD PH
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3300
Practice Address - Country:US
Practice Address - Phone:718-830-9274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist