Provider Demographics
NPI:1770107161
Name:PENDERGRAFT, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PENDERGRAFT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 WONDER WORLD DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7969
Mailing Address - Country:US
Mailing Address - Phone:512-393-3325
Mailing Address - Fax:
Practice Address - Street 1:3915 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-1230
Practice Address - Country:US
Practice Address - Phone:541-746-6816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX845030163W00000X
TX1017838363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse