Provider Demographics
NPI:1003212184
Name:MCCLENDON, MELINDA (RN, AGNP-BC)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:MCCLENDON
Suffix:
Gender:F
Credentials:RN, AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W WILLIAM CANNON DR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5281
Mailing Address - Country:US
Mailing Address - Phone:512-416-7246
Mailing Address - Fax:512-275-2833
Practice Address - Street 1:4110 BRIARGATE PKWY STE 405
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7838
Practice Address - Country:US
Practice Address - Phone:719-365-7300
Practice Address - Fax:512-275-2833
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126900363L00000X, 363LA2200X, 363LG0600X
COC-APN.0000696-C-NP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX341829502Medicaid
CO9000145106Medicaid
TX341829501Medicaid
TX382777YL9JMedicare PIN