Provider Demographics
NPI:1669453049
Name:PRUETT, CHARLEEN L (ANP)
Entity Type:Individual
Prefix:MS
First Name:CHARLEEN
Middle Name:L
Last Name:PRUETT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:23606 SHEPERD RD.
Mailing Address - City:CLATSKANIE
Mailing Address - State:OR
Mailing Address - Zip Code:97016-0276
Mailing Address - Country:US
Mailing Address - Phone:503-728-4770
Mailing Address - Fax:
Practice Address - Street 1:23606 SHEPARD RD
Practice Address - Street 2:
Practice Address - City:CLATSKANIE
Practice Address - State:OR
Practice Address - Zip Code:97016-2331
Practice Address - Country:US
Practice Address - Phone:503-728-4770
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR90007050363LA2200X
WAAP30002308363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR78969Medicaid
OR78969Medicaid
OR0000XCDBLMedicare ID - Type Unspecified