Healthcare Provider Details

I. General information

NPI: 1366148306
Provider Name (Legal Business Name): MADISON PAIGE PENDERGRAFT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 S NATIONAL AVE STE 600
SPRINGFIELD MO
65807-5288
US

IV. Provider business mailing address

PO BOX 749495
ATLANTA GA
30374-9495
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-4880
  • Fax: 417-882-7843
Mailing address:
  • Phone: 866-266-0555
  • Fax: 866-266-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2018024713
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2023006102
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: