Provider Demographics
NPI:1194587055
Name:PENDLETON-WALLACE, NYETTA (MED)
Entity type:Individual
Prefix:
First Name:NYETTA
Middle Name:
Last Name:PENDLETON-WALLACE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 TWINING RD STE 120
Mailing Address - Street 2:
Mailing Address - City:DRESHER
Mailing Address - State:PA
Mailing Address - Zip Code:19025-1832
Mailing Address - Country:US
Mailing Address - Phone:215-254-6000
Mailing Address - Fax:215-754-1705
Practice Address - Street 1:721 DRESHER RD STE 1100
Practice Address - Street 2:
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-2216
Practice Address - Country:US
Practice Address - Phone:215-254-6000
Practice Address - Fax:215-754-1705
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator