Provider Demographics
NPI:1790940666
Name:PRUITT, LATASHA (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-5004
Mailing Address - Country:US
Mailing Address - Phone:864-288-3672
Mailing Address - Fax:
Practice Address - Street 1:3901 PELHAM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-5004
Practice Address - Country:US
Practice Address - Phone:864-288-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3619363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA32939090Medicare UPIN
SCAA32936067Medicare PIN