Provider Demographics
NPI:1366148306
Name:PENDERGRAFT, MADISON PAIGE (APRN)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:PAIGE
Last Name:PENDERGRAFT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:866-266-0555
Mailing Address - Fax:866-266-4999
Practice Address - Street 1:3850 S NATIONAL AVE STE 600
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5288
Practice Address - Country:US
Practice Address - Phone:417-882-4880
Practice Address - Fax:417-882-7843
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2018024713163W00000X
MO2023006102363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse