1598080160 NPI number — MELINDA K PEMBERTON FNP-BC

Table of content: MELINDA K PEMBERTON FNP-BC (NPI 1598080160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598080160 NPI number — MELINDA K PEMBERTON FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEMBERTON
Provider First Name:
MELINDA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598080160
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5301 FARAON ST STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64506-3512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-271-1066
Provider Business Mailing Address Fax Number:
816-271-6786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 HEARTLAND RD STE 3800
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64506-6201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-671-4800
Provider Business Practice Location Address Fax Number:
816-233-4021
Provider Enumeration Date:
04/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  2000149865 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP143639 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200641200A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1598080160 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00847174 . This is a "RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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