Provider Demographics
NPI:1184045940
Name:PRUITT, PAMELA JANE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JANE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 TEXAS HIGHWAY 43
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-7252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:570 TEXAS HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-7252
Practice Address - Country:US
Practice Address - Phone:903-824-0508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18899235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist