Provider Demographics
NPI:1114700606
Name:PRUITT, AMANDA (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E EDWARDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1369
Mailing Address - Country:US
Mailing Address - Phone:618-296-6085
Mailing Address - Fax:
Practice Address - Street 1:101 E EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1369
Practice Address - Country:US
Practice Address - Phone:618-296-6085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.369031163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse