Provider Demographics
NPI:1336902949
Name:PENDLETON, TRAYDACIA KIARA (CRNM, MSN)
Entity type:Individual
Prefix:MS
First Name:TRAYDACIA
Middle Name:KIARA
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:CRNM, MSN
Other - Prefix:MS
Other - First Name:TRAYDACIA
Other - Middle Name:KIARA
Other - Last Name:LOVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:1647 WOODBROOKE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-8502
Practice Address - Country:US
Practice Address - Phone:410-546-2424
Practice Address - Fax:410-742-6633
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC007293367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid