Provider Demographics
NPI:1104212315
Name:PRUETTE, MEGAN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELIZABETH
Last Name:PRUETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:PRUETTE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2106 GREENWICH PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-1373
Mailing Address - Country:US
Mailing Address - Phone:949-633-6045
Mailing Address - Fax:
Practice Address - Street 1:77 VILCOM CENTER DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-1788
Practice Address - Country:US
Practice Address - Phone:984-974-5217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2019-009332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty