Provider Demographics
NPI:1689009169
Name:PRENTICE, CASSIDY H (PAC)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:H
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CASSIDY
Other - Middle Name:
Other - Last Name:HENNEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7867
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0867
Mailing Address - Country:US
Mailing Address - Phone:252-451-2700
Mailing Address - Fax:252-451-2702
Practice Address - Street 1:903 N ARENDELL AVE
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-2307
Practice Address - Country:US
Practice Address - Phone:919-404-0445
Practice Address - Fax:919-404-1642
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04382363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1689009169Medicaid
NC1689009169Medicaid