Provider Demographics
NPI:1235296146
Name:GLENDA PRUITT PC
Entity Type:Organization
Organization Name:GLENDA PRUITT PC
Other - Org Name:STRAWN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:RN CFNP
Authorized Official - Phone:254-672-5200
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:119 CENTRAL AVE.
Mailing Address - City:STRAWN
Mailing Address - State:TX
Mailing Address - Zip Code:76475-0006
Mailing Address - Country:US
Mailing Address - Phone:254-672-5200
Mailing Address - Fax:
Practice Address - Street 1:119 CENTRAL AVE.
Practice Address - Street 2:119 CENTRAL AVE.
Practice Address - City:STRAWN
Practice Address - State:TX
Practice Address - Zip Code:76475-0006
Practice Address - Country:US
Practice Address - Phone:254-672-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX220196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1679686257OtherINDIVIDUAL NPI NUMBER
TX1676637Medicaid
TX00185XMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER