Provider Demographics
NPI:1821689068
Name:PRUITT, ANNA DAVENPORT SHEALY (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:DAVENPORT SHEALY
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5970 FAIRVIEW RD STE 430
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5970 FAIRVIEW RD STE 430
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3117
Practice Address - Country:US
Practice Address - Phone:704-503-9884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-31
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program