1962524652 NPI number — MELINDA DAWN PENDERGRAFT CRNA

Table of content: MELINDA DAWN PENDERGRAFT CRNA (NPI 1962524652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962524652 NPI number — MELINDA DAWN PENDERGRAFT CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENDERGRAFT
Provider First Name:
MELINDA
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREGORY
Provider Other First Name:
MELINDA
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962524652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10310 STATE LINE RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LEAWOOD
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66206-2658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-647-4100
Provider Business Mailing Address Fax Number:
913-647-4121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 NE SAINT LUKES BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEES SUMMIT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64086-6000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-347-5800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2007

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: 367500000X , with the licence number:  2001017791 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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