Provider Demographics
NPI:1447587944
Name:PRENDERGAST, SUSAN M (ARNP)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:M
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 SW VINCENNES ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3771
Mailing Address - Country:US
Mailing Address - Phone:954-821-9337
Mailing Address - Fax:
Practice Address - Street 1:3533 SW VINCENNES ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-3771
Practice Address - Country:US
Practice Address - Phone:954-821-9337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3201922363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3066631 00Medicaid