Provider Demographics
NPI:1538654405
Name:PRUITT, TERRI AMANDA (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:AMANDA
Last Name:PRUITT
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 REDWOOD PL
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-6050
Mailing Address - Country:US
Mailing Address - Phone:918-931-2996
Mailing Address - Fax:
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-24
Last Update Date:2018-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK88775363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health