Provider Demographics
NPI:1093021826
Name:PRUITT, BROOKE NICOLE (ANP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:ANP
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 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-8000
Mailing Address - Fax:870-934-3630
Practice Address - Street 1:4802 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-8413
Practice Address - Country:US
Practice Address - Phone:870-936-8000
Practice Address - Fax:870-934-3630
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03418 ANP363L00000X
ARA003418363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185886758Medicaid
ARSV661Medicare PIN