Provider Demographics
NPI:1164041521
Name:ADRIENNE L. PRENTISS, MD PA
Entity Type:Organization
Organization Name:ADRIENNE L. PRENTISS, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRENTISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-251-1225
Mailing Address - Street 1:1704 TENNISON PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6297
Mailing Address - Country:US
Mailing Address - Phone:817-251-1225
Mailing Address - Fax:
Practice Address - Street 1:1704 TENNISON PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6297
Practice Address - Country:US
Practice Address - Phone:817-251-1225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty