Provider Demographics
NPI:1841794476
Name:PRUITT, LAUREN (LPTA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:MRS
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:PRUITT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPTA
Mailing Address - Street 1:27311 DRUMMONDTOWN RD
Mailing Address - Street 2:
Mailing Address - City:ONLEY
Mailing Address - State:VA
Mailing Address - Zip Code:23418-2219
Mailing Address - Country:US
Mailing Address - Phone:757-710-7968
Mailing Address - Fax:
Practice Address - Street 1:20480 MARKET ST
Practice Address - Street 2:
Practice Address - City:ONANCOCK
Practice Address - State:VA
Practice Address - Zip Code:23417-4309
Practice Address - Country:US
Practice Address - Phone:757-710-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603103225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant