Provider Demographics
NPI:1780005017
Name:PENDERGAST, LAUREN M (RD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SKIPPACK PIKE STE 300
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3725
Practice Address - Country:US
Practice Address - Phone:215-628-4454
Practice Address - Fax:302-651-2757
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDN-0000539133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered