Provider Demographics
NPI:1801204052
Name:PENDERGAST, JULIE (RN)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11390 W THEODORE TRECKER WAY
Mailing Address - Street 2:
Mailing Address - City:WEST MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1135
Mailing Address - Country:US
Mailing Address - Phone:414-928-1401
Mailing Address - Fax:414-328-1402
Practice Address - Street 1:11390 W THEODORE TRECKER WAY
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-1135
Practice Address - Country:US
Practice Address - Phone:414-928-1401
Practice Address - Fax:414-328-1402
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI221281-30163W00000X
WI221282163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163W00000XNursing Service ProvidersRegistered Nurse