Provider Demographics
NPI:1821447681
Name:PRENDERGAST, ELENA CHRISTINA (FNP-C)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:CHRISTINA
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MS
Other - First Name:ELENA
Other - Middle Name:CHRISTINA
Other - Last Name:VILLEGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:211 BOBBY JONES EXPY STE C
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-5253
Mailing Address - Country:US
Mailing Address - Phone:706-860-3355
Mailing Address - Fax:
Practice Address - Street 1:211 BOBBY JONES EXPY STE C
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-5253
Practice Address - Country:US
Practice Address - Phone:706-860-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-11
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN202093363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily