Provider Demographics
NPI:1730493446
Name:PENDERGAST, MELINDA ROSE (BSN RN)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:ROSE
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:BSN RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:221 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2749
Mailing Address - Country:US
Mailing Address - Phone:607-734-3646
Mailing Address - Fax:
Practice Address - Street 1:106 S PERRY ST
Practice Address - Street 2:
Practice Address - City:WATKINS GLEN
Practice Address - State:NY
Practice Address - Zip Code:14891-1615
Practice Address - Country:US
Practice Address - Phone:607-535-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY566633-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse