Provider Demographics
NPI:1912134529
Name:PRINDAVILLE, BREA SHAY (MD)
Entity Type:Individual
Prefix:DR
First Name:BREA
Middle Name:SHAY
Last Name:PRINDAVILLE
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 1:526 MAIN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3301
Mailing Address - Country:US
Mailing Address - Phone:978-371-7010
Mailing Address - Fax:978-371-0522
Practice Address - Street 1:148 W RIVER ST STE 1B
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904
Practice Address - Country:US
Practice Address - Phone:401-273-9310
Practice Address - Fax:401-273-1270
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI15774207NP0225X, 208000000X, 207N00000X
RIMD15774207NP0225X
MA265523207N00000X
KS9407984207NP0225X, 208000000X
MO2012017793208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207N00000XAllopathic & Osteopathic PhysiciansDermatology