Healthcare Provider Details

I. General information

NPI: 1912134529
Provider Name (Legal Business Name): BREA SHAY PRINDAVILLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 W RIVER ST STE 1B
PROVIDENCE RI
02904
US

IV. Provider business mailing address

526 MAIN ST STE 302
ACTON MA
01720-3301
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-9310
  • Fax: 401-273-1270
Mailing address:
  • Phone: 978-371-7010
  • Fax: 978-371-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberMD15774
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number265523
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number265523
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD15774
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD15774
License Number StateRI
# 6
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number265523
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: