Provider Demographics
NPI:1841854700
Name:PRENDERGAST, KATELYN (RN BSN)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 684
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-0684
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1605 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-5137
Practice Address - Country:US
Practice Address - Phone:503-982-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201900755RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse