Provider Demographics
NPI:1073976007
Name:PRUITT, TERA
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
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 1:6191 CROOKED CREEK DR
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-5008
Mailing Address - Country:US
Mailing Address - Phone:404-574-3091
Mailing Address - Fax:
Practice Address - Street 1:6191 CROOKED CREEK DR
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-5008
Practice Address - Country:US
Practice Address - Phone:404-574-3091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator