Provider Demographics
NPI:1902018633
Name:PRENDERGAST, ANGELA M (STNA)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:M
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:BAGSHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:STNA
Mailing Address - Street 1:14870 GEORGETOWN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657-9134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14870 GEORGETOWN ST NE
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-9134
Practice Address - Country:US
Practice Address - Phone:330-862-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH501064030106376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH501064030106OtherSTNA REGISTRATION NUMBER
OH2717500Medicaid