Provider Demographics
NPI:1720436645
Name:PENDERGRAFT, AMY (FNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PENDERGRAFT
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1691 GALISTEO ST STE C
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4781
Mailing Address - Country:US
Mailing Address - Phone:505-983-5631
Mailing Address - Fax:
Practice Address - Street 1:1691 GALISTEO ST STE C
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4781
Practice Address - Country:US
Practice Address - Phone:505-983-5631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81358363LF0000X
NM879769133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric