Provider Demographics
NPI:1477879351
Name:PRUITT, SHENISE LASTINE
Entity Type:Individual
Prefix:
First Name:SHENISE
Middle Name:LASTINE
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 1:9648 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:OLIVETTE
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3002
Mailing Address - Country:US
Mailing Address - Phone:314-641-9930
Mailing Address - Fax:
Practice Address - Street 1:9648 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132-3002
Practice Address - Country:US
Practice Address - Phone:314-641-9930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor