Provider Demographics
NPI:1962782128
Name:PRENTICE, SHAVON (APRN)
Entity type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740012
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5743 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1305
Practice Address - Country:US
Practice Address - Phone:502-444-6008
Practice Address - Fax:502-586-7173
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003614A363LA2200X
KY3007023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100200290Medicaid
KYK045351Medicare PIN
KYK045355Medicare PIN
KYK045352Medicare PIN
KYK045354Medicare PIN
KY7100200290Medicaid
KYK045356Medicare PIN
KYK045353Medicare PIN