Provider Demographics
NPI:1649583139
Name:PRUIETT, KELLEY (CNP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:PRUIETT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 BRIGHAM DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7114
Mailing Address - Country:US
Mailing Address - Phone:419-872-7703
Mailing Address - Fax:419-872-1704
Practice Address - Street 1:1601 BRIGHAM DR
Practice Address - Street 2:SUITE 120
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7114
Practice Address - Country:US
Practice Address - Phone:419-872-7703
Practice Address - Fax:419-872-1704
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-276458163W00000X
OHNP-11612363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9384591OtherAETNA
OHP00962317OtherRRMC
OH000000671121OtherANTHEM
OH3076442Medicaid
OH9384591OtherAETNA