Provider Demographics
NPI:1609801232
Name:PRENTICE, ROSEMARY L (NP)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:L
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6143
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9422
Practice Address - Country:US
Practice Address - Phone:207-283-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081225363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME335300099Medicaid
NH30346873Medicaid
ME335300099Medicaid
MEP00750358Medicare PIN