Provider Demographics
NPI:1407154883
Name:PRUITT, OLWYN RENITA
Entity Type:Individual
Prefix:MS
First Name:OLWYN
Middle Name:RENITA
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 1:1467 PHILLIPS ROAD 241
Mailing Address - Street 2:
Mailing Address - City:LEXA
Mailing Address - State:AR
Mailing Address - Zip Code:72355-8485
Mailing Address - Country:US
Mailing Address - Phone:702-428-2300
Mailing Address - Fax:
Practice Address - Street 1:2707 BROWNS LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7213
Practice Address - Country:US
Practice Address - Phone:702-428-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner