Provider Demographics
NPI:1720017395
Name:PRUGH, SALLIE I (CPNP)
Entity Type:Individual
Prefix:MS
First Name:SALLIE
Middle Name:I
Last Name:PRUGH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8003
Mailing Address - Country:US
Mailing Address - Phone:803-434-7950
Mailing Address - Fax:803-434-8606
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 400
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6877
Practice Address - Country:US
Practice Address - Phone:803-434-7950
Practice Address - Fax:803-434-8606
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2421363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0311Medicaid
SCP08151Medicare PIN
P08151Medicare UPIN