Provider Demographics
NPI:1225230402
Name:PRINCE, EDNA JACQUELINE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDNA
Middle Name:JACQUELINE
Last Name:PRINCE
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 1:2093 HALLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38107-4704
Mailing Address - Country:US
Mailing Address - Phone:901-276-7169
Mailing Address - Fax:
Practice Address - Street 1:1400 DALE BUMPERS ROAD
Practice Address - Street 2:FCC FORREST CITY
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72336
Practice Address - Country:US
Practice Address - Phone:870-630-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17426208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice