Provider Demographics
NPI:1619738309
Name:PRUITT, ELLEN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
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 1:4410 CLAIBORNE SQ E
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2071
Mailing Address - Country:US
Mailing Address - Phone:888-964-6681
Mailing Address - Fax:888-662-0859
Practice Address - Street 1:4410 CLAIBORNE SQ E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2071
Practice Address - Country:US
Practice Address - Phone:888-964-6681
Practice Address - Fax:888-662-0859
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402209077124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist