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General NPI Number Information
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NPI Number | 1295111987
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Entity Type | Organization
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Legal Business Name | VIRGINIA PRENDERGAST LLC
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Dates
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Enumeration Date | 08/04/2015
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Last Update Date | 08/04/2015
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Provider Practice Location Address
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Address Line | 1424 E MARSHALL AVE
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City | PHOENIX
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State | AZ
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Zip | 85014-2358
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Country | US
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Telephone | 480-220-4688
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Fax | 602-406-4969
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Provider Business Mailing Address
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Address Line | 1424 E MARSHALL AVE
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City | PHOENIX
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State | AZ
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Zip | 85014-2358
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Country | US
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Telephone | 480-220-4688
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Fax | 602-406-4969
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Authorized Official
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Title or Position | DIRECTOR
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Name | VIRGINIA PRENDERGAST
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Credential |
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Telephone | 480-220-4688
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | RN039088
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License Number State | AZ
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