Healthcare Provider Details

I. General information

NPI: 1700795366
Provider Name (Legal Business Name): ANITA R PRENDERGAST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANITA R MILES

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 PEACHTREE ST NE
ATLANTA GA
30308-7400
US

IV. Provider business mailing address

3250 BUFORD HWY APT 1420
DULUTH GA
30096-3694
US

V. Phone/Fax

Practice location:
  • Phone: 347-604-3013
  • Fax:
Mailing address:
  • Phone: 347-604-3013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT008633
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: