Provider Demographics
NPI:1194405415
Name:PRENDERGAST, SHIONA
Entity type:Individual
Prefix:
First Name:SHIONA
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 MISS AMBER WAY
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-4033
Mailing Address - Country:US
Mailing Address - Phone:470-723-7519
Mailing Address - Fax:
Practice Address - Street 1:1024 MISS AMBER WAY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-4033
Practice Address - Country:US
Practice Address - Phone:470-723-7519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0012494405376K00000X
376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide