Provider Demographics
NPI:1114304284
Name:PRUITT, ROSEANN (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:ROSEANN
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 REDTAIL RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-7070
Mailing Address - Country:US
Mailing Address - Phone:978-618-7329
Mailing Address - Fax:
Practice Address - Street 1:1762 CLIFTON RD NE
Practice Address - Street 2:STE 1650
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4001
Practice Address - Country:US
Practice Address - Phone:978-618-7329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0019442255A2300X
GA363A00000X
GA9174363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant