Provider Demographics
NPI:1700607306
Name:PENDERGAST, MILISSA
Entity type:Individual
Prefix:
First Name:MILISSA
Middle Name:
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 NEW SCOTLAND AVE UNIT D
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3474
Mailing Address - Country:US
Mailing Address - Phone:518-549-6894
Mailing Address - Fax:
Practice Address - Street 1:75 NEW SCOTLAND AVE UNIT D
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3474
Practice Address - Country:US
Practice Address - Phone:518-549-6894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281573-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty