Provider Demographics
NPI:1841619350
Name:PRUITT, LAURIE (LPN)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 GREEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29341-3209
Mailing Address - Country:US
Mailing Address - Phone:864-206-6770
Mailing Address - Fax:864-487-1245
Practice Address - Street 1:840 GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-3209
Practice Address - Country:US
Practice Address - Phone:864-206-6770
Practice Address - Fax:864-487-1245
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-11
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP39010164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1538119276Medicaid