Healthcare Provider Details

I. General information

NPI: 1720436645
Provider Name (Legal Business Name): AMY PENDERGRAFT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 04/03/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 GALISTEO ST STE C
SANTA FE NM
87505-4781
US

IV. Provider business mailing address

1691 GALISTEO ST STE C
SANTA FE NM
87505-4781
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-5631
  • Fax:
Mailing address:
  • Phone: 505-983-5631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number81358
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number879769
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: