Provider Demographics
NPI:1578085395
Name:PRUITT, ANNA BETH
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:BETH
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 1:299 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-2155
Mailing Address - Country:US
Mailing Address - Phone:770-867-2120
Mailing Address - Fax:
Practice Address - Street 1:299 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2155
Practice Address - Country:US
Practice Address - Phone:770-867-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008038207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine