Provider Demographics
NPI:1164749974
Name:PRUITT, SKY R (PT)
Entity Type:Individual
Prefix:MR
First Name:SKY
Middle Name:R
Last Name:PRUITT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 N LAKEWOOD DR
Mailing Address - Street 2:NORTH IDAHO PHYSICAL THERAPY
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2634
Mailing Address - Country:US
Mailing Address - Phone:208-664-8194
Mailing Address - Fax:208-667-1847
Practice Address - Street 1:1917 N LAKEWOOD DR
Practice Address - Street 2:NORTH IDAHO PHYSICAL THERAPY
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2634
Practice Address - Country:US
Practice Address - Phone:208-664-8194
Practice Address - Fax:208-667-1847
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2312225100000X
IDPT-3182225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist