Provider Demographics
NPI:1790235877
Name:PRUTZMAN, CARLY MICHELE (APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:MICHELE
Last Name:PRUTZMAN
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:MICHELE
Other - Last Name:PRUITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:3333 WINDMILL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73165-7382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1503 S MISSION ST STE A
Practice Address - Street 2:
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005-5815
Practice Address - Country:US
Practice Address - Phone:405-247-1100
Practice Address - Fax:405-247-1155
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK86017363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily