Provider Demographics
NPI:1194788992
Name:PENDLETON, MARY KATHERINE (APRN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERINE
Last Name:PENDLETON
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 462
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-0462
Mailing Address - Country:US
Mailing Address - Phone:815-732-2499
Mailing Address - Fax:815-732-6077
Practice Address - Street 1:1658 S IL ROUTE 2
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061-9514
Practice Address - Country:US
Practice Address - Phone:815-732-2499
Practice Address - Fax:815-732-6077
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014306363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209014306OtherLICENSE
R28C500Medicare ID - Type Unspecified