Provider Demographics
NPI:1962503326
Name:BARRETT, PRUDENCE LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:PRUDENCE
Middle Name:LYNN
Last Name:BARRETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2516 NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1937
Mailing Address - Country:US
Mailing Address - Phone:269-983-6518
Mailing Address - Fax:269-983-0955
Practice Address - Street 1:2516 NILES AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1937
Practice Address - Country:US
Practice Address - Phone:269-983-6518
Practice Address - Fax:269-983-0955
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301044725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1537773Medicaid