Provider Demographics
NPI:1003520347
Name:PRUITT, AMELIE RHOSHUNDA
Entity Type:Individual
Prefix:
First Name:AMELIE
Middle Name:RHOSHUNDA
Last Name:PRUITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 PACIFIC AVE APT 1706
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4964
Mailing Address - Country:US
Mailing Address - Phone:469-577-5491
Mailing Address - Fax:
Practice Address - Street 1:6465 E MOCKINGBIRD LN STE 344
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-7018
Practice Address - Country:US
Practice Address - Phone:469-577-5491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT137429225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist