Provider Demographics
NPI:1093317455
Name:PRUETT, ALLIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ALLIE
Middle Name:
Last Name:PRUETT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4312
Mailing Address - Country:US
Mailing Address - Phone:904-345-7310
Mailing Address - Fax:
Practice Address - Street 1:3901 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4312
Practice Address - Country:US
Practice Address - Phone:904-345-6920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052138852251P0200X
FLPT36210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics