Provider Demographics
NPI:1932701604
Name:PEMBERTON, COURTNEY (APRN)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:F
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-757-2927
Mailing Address - Fax:859-341-0203
Practice Address - Street 1:3535 PENTAGON BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-1705
Practice Address - Country:US
Practice Address - Phone:937-702-4024
Practice Address - Fax:937-702-4035
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015281363L00000X
OH0038556363LC0200X
OHAPRN.CNP.0038556363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine