Healthcare Provider Details

I. General information

NPI: 1629993613
Provider Name (Legal Business Name): EVA GRACE PRENTISS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 SPRING ST
GULFPORT MS
39507-3418
US

IV. Provider business mailing address

1287 SPRING ST
GULFPORT MS
39507-3418
US

V. Phone/Fax

Practice location:
  • Phone: 228-265-9606
  • Fax: 888-430-7522
Mailing address:
  • Phone: 228-265-9606
  • Fax: 888-430-7522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT8272
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: