Provider Demographics
NPI:1083610133
Name:PRENTISS, ADRIENNE L (MD)
Entity Type:Individual
Prefix:DR
First Name:ADRIENNE
Middle Name:L
Last Name:PRENTISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W COLLEGE ST
Mailing Address - Street 2:STE 510
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3589
Mailing Address - Country:US
Mailing Address - Phone:817-251-1225
Mailing Address - Fax:817-251-1228
Practice Address - Street 1:1600 W COLLEGE ST
Practice Address - Street 2:STE 510
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3589
Practice Address - Country:US
Practice Address - Phone:817-251-1225
Practice Address - Fax:817-251-1228
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
TXK8817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0060HPOtherBCBS
TXH03548Medicare UPIN
TX00283FMedicare ID - Type Unspecified