Provider Demographics
NPI:1679577555
Name:PRUITT, KATHRYN CLAIRE (APN)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:CLAIRE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8820 TURKEY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-8096
Mailing Address - Country:US
Mailing Address - Phone:502-810-4164
Mailing Address - Fax:
Practice Address - Street 1:111 CHASE ST
Practice Address - Street 2:
Practice Address - City:BYHALIA
Practice Address - State:MS
Practice Address - Zip Code:38611
Practice Address - Country:US
Practice Address - Phone:502-810-4164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19930363LF0000X
MS895684363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP64175Medicare UPIN
AR5X080Medicare ID - Type Unspecified