Provider Demographics
NPI:1679686257
Name:PRUITT, GLENDA FAYE (RN CFNP)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:FAYE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:RN CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 JANE LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-5519
Mailing Address - Country:US
Mailing Address - Phone:817-472-7727
Mailing Address - Fax:
Practice Address - Street 1:2505 JANE LN
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-5519
Practice Address - Country:US
Practice Address - Phone:817-713-9849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX220196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018845002Medicaid
TX167663701Medicaid
TX167663701Medicaid