Provider Demographics
NPI:1316413255
Name:PRUITT, LORI GAYLE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:GAYLE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 MACKAY DR
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-8428
Mailing Address - Country:US
Mailing Address - Phone:830-285-0929
Mailing Address - Fax:
Practice Address - Street 1:575 HILL COUNTRY DR
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6024
Practice Address - Country:US
Practice Address - Phone:830-258-7762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX664299163WL0100X
TXAP1139202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant