Healthcare Provider Details

I. General information

NPI: 1881127074
Provider Name (Legal Business Name): DESEREE PRENTICE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6130 NOLENSVILLE RD
NASHVILLE TN
37211-6813
US

IV. Provider business mailing address

300 20TH AVE N STE 403
NASHVILLE TN
37203-5180
US

V. Phone/Fax

Practice location:
  • Phone: 615-284-1450
  • Fax: 629-208-2691
Mailing address:
  • Phone: 615-284-4029
  • Fax: 629-802-9993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3535
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: