Provider Demographics
NPI:1881037935
Name:PRENDERGAST, PRINCESS MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:MARIE
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 1:3000 HUNTERS CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6901
Mailing Address - Country:US
Mailing Address - Phone:407-857-2502
Mailing Address - Fax:407-857-1855
Practice Address - Street 1:3000 HUNTERS CREEK BLVD STE 208
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6901
Practice Address - Country:US
Practice Address - Phone:407-857-2502
Practice Address - Fax:407-857-1855
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9233414363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009116000Medicaid