Healthcare Provider Details

I. General information

NPI: 1831738251
Provider Name (Legal Business Name): PEGGY PRENDERGAST BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 09/29/2026
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9649 W 55TH ST
COUNTRYSIDE IL
60525-3699
US

IV. Provider business mailing address

9649 W 55TH ST
COUNTRYSIDE IL
60525-3699
US

V. Phone/Fax

Practice location:
  • Phone: 708-352-3580
  • Fax: 708-352-2715
Mailing address:
  • Phone: 708-352-3580
  • Fax: 708-352-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.244777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: