Provider Demographics
NPI:1104979558
Name:PRENDERGAST, KAREN LEE (RD,LD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LEE
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 RIVERSIDE PKWY.
Mailing Address - Street 2:P.O. BOX 897
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045
Mailing Address - Country:US
Mailing Address - Phone:770-339-4260
Mailing Address - Fax:770-339-4297
Practice Address - Street 1:8203 HAZELBRAND RD NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1510
Practice Address - Country:US
Practice Address - Phone:770-786-9086
Practice Address - Fax:770-786-0715
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001340133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered