Provider Demographics
NPI:1407515570
Name:PRUITT, COURTNEY WILBURN (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:WILBURN
Last Name:PRUITT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LEIGH
Other - Last Name:WILBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2401 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5374
Mailing Address - Country:US
Mailing Address - Phone:662-234-0424
Mailing Address - Fax:662-234-0485
Practice Address - Street 1:2401 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5374
Practice Address - Country:US
Practice Address - Phone:662-234-0424
Practice Address - Fax:662-234-0485
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905056363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology