Provider Demographics
NPI:1598080160
Name:PEMBERTON, MELINDA K (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:K
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 FARAON ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3512
Mailing Address - Country:US
Mailing Address - Phone:816-271-1066
Mailing Address - Fax:816-271-6786
Practice Address - Street 1:901 HEARTLAND RD STE 3800
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-6201
Practice Address - Country:US
Practice Address - Phone:816-671-4800
Practice Address - Fax:816-233-4021
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000149865363LF0000X
TXAP143639363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200641200AMedicaid
MO1598080160Medicaid
MOP00847174OtherRR MEDICARE
KS200641200AMedicaid