Provider Demographics
NPI:1194418939
Name:PENDERGRASS, TIFFANY T (FNP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:T
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 MEDICAL PARK DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5797
Mailing Address - Country:US
Mailing Address - Phone:865-988-6575
Mailing Address - Fax:865-988-6066
Practice Address - Street 1:689 MEDICAL PARK DR STE 201
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5797
Practice Address - Country:US
Practice Address - Phone:865-988-6575
Practice Address - Fax:865-988-6066
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32294363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner