Provider Demographics
NPI:1124689963
Name:PRENDERGAST, SAMANTHA JO (FNP-BC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 REDFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2708
Mailing Address - Country:US
Mailing Address - Phone:315-269-9443
Mailing Address - Fax:
Practice Address - Street 1:1656 CHAMPLIN AVE STE 406
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-269-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily