Healthcare Provider Details

I. General information

NPI: 1578633657
Provider Name (Legal Business Name): VIRGINIA PRENDERGAST NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 E MARSHALL AVE
PHOENIX AZ
85014-2358
US

IV. Provider business mailing address

1424 E MARSHALL AVE
PHOENIX AZ
85014-2358
US

V. Phone/Fax

Practice location:
  • Phone: 480-220-4688
  • Fax: 602-406-4969
Mailing address:
  • Phone: 480-220-4688
  • Fax: 602-406-4969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN039088
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP6877
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: