Provider Demographics
NPI:1770459364
Name:PENDARVIS, JUSTEENA MELLINE
Entity type:Individual
Prefix:
First Name:JUSTEENA
Middle Name:MELLINE
Last Name:PENDARVIS
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 1:19020 SE 29TH ST
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-6340
Mailing Address - Country:US
Mailing Address - Phone:580-510-9121
Mailing Address - Fax:
Practice Address - Street 1:1613 SE 66TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73149-5203
Practice Address - Country:US
Practice Address - Phone:405-616-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-13
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK205767164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse