Provider Demographics
NPI:1114012911
Name:PRUITT, KRISTEN AGNEW (MS, PT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:AGNEW
Last Name:PRUITT
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 ENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-4663
Mailing Address - Country:US
Mailing Address - Phone:678-450-1174
Mailing Address - Fax:678-450-1174
Practice Address - Street 1:4615 ENFIELD DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-4663
Practice Address - Country:US
Practice Address - Phone:678-450-1174
Practice Address - Fax:678-450-1174
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004847225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10054142OtherAMERIGROUP PROVIDER #
GAPT004847OtherPHYSICAL THERAPY LICENSE