Healthcare Provider Details

I. General information

NPI: 1023902103
Provider Name (Legal Business Name): HANNA MARIE PRENDEVILLE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2025
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VFW PKWY
WEST ROXBURY MA
02132-4927
US

IV. Provider business mailing address

1400 VFW PKWY
WEST ROXBURY MA
02132-4927
US

V. Phone/Fax

Practice location:
  • Phone: 518-812-4820
  • Fax:
Mailing address:
  • Phone: 857-203-3165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT8324
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: