Provider Demographics
NPI:1033189352
Name:PRENDERGAST, KELLEY ANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:ANN
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:326 NICHOLS ROAD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420
Mailing Address - Country:US
Mailing Address - Phone:978-878-8100
Mailing Address - Fax:978-878-8537
Practice Address - Street 1:175 CONNORS STREET
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440
Practice Address - Country:US
Practice Address - Phone:978-410-6121
Practice Address - Fax:978-410-6109
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAAP2003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant