Provider Demographics
NPI:1245575539
Name:PRUITT, TONYA FISHER (FNP)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:FISHER
Last Name:PRUITT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4039 RIDLEY FIELD DR
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6081
Mailing Address - Country:US
Mailing Address - Phone:919-554-4158
Mailing Address - Fax:
Practice Address - Street 1:1614 NC HIGHWAY 56
Practice Address - Street 2:
Practice Address - City:CREEDMOOR
Practice Address - State:NC
Practice Address - Zip Code:27522-8297
Practice Address - Country:US
Practice Address - Phone:919-582-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily