Healthcare Provider Details

I. General information

NPI: 1659770071
Provider Name (Legal Business Name): MARY BETH PRENDERGAST RN, PHN, MN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

3851 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8489
  • Fax: 619-692-8827
Mailing address:
  • Phone: 619-692-8489
  • Fax: 619-692-8827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number335126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: