Provider Demographics
NPI:1033505524
Name:PRUITT, AMANDA KINNEY (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KINNEY
Last Name:PRUITT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:KINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:200 COLLEGE ST
Mailing Address - Street 2:P.O. BOX 5158
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304
Mailing Address - Country:US
Mailing Address - Phone:864-582-2411
Mailing Address - Fax:864-594-0040
Practice Address - Street 1:200 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-582-2411
Practice Address - Fax:864-594-0040
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC51900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCF2976067OtherMEDICARE PIN
SCSCF2976121OtherMEDICARE PIN
SCSCD368J577OtherMEDICARE PIN
SCSCF2976084OtherMEDICARE PIN
SC519004Medicaid
SCSCD3684862OtherMEDICARE