Provider Demographics
NPI:1972645117
Name:PRUETT, TIMOTHY O (FNP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:O
Last Name:PRUETT
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1900 S NATIONAL AVE
Practice Address - Street 2:SUITE 3600
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2265
Practice Address - Country:US
Practice Address - Phone:417-820-3911
Practice Address - Fax:417-820-3924
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112446363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO174073OtherMO BLUE SHIELD
MO428328702Medicaid
AR82543OtherARK BLUE SHIELD
MO428328702Medicaid
AR82543OtherARK BLUE SHIELD