Provider Demographics
NPI:1588606404
Name:PRENTICE, HOLLY DIAHN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:DIAHN
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-3361
Mailing Address - Country:US
Mailing Address - Phone:626-963-9402
Mailing Address - Fax:626-914-5316
Practice Address - Street 1:440 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-3361
Practice Address - Country:US
Practice Address - Phone:626-963-9402
Practice Address - Fax:626-914-5316
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15115363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical