Provider Demographics
NPI:1235783127
Name:PONDER, ELAINA (FNP-C)
Entity type:Individual
Prefix:
First Name:ELAINA
Middle Name:
Last Name:PONDER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50018 SIMS LN
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-8859
Mailing Address - Country:US
Mailing Address - Phone:662-315-5612
Mailing Address - Fax:
Practice Address - Street 1:1506 U.S. 278 SUITE A
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821
Practice Address - Country:US
Practice Address - Phone:662-305-9149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902890363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily