Provider Demographics
NPI:1295518058
Name:PRUITT, SHANNON (DNP, APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:DNP, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9650 NALL AVE
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-2952
Mailing Address - Country:US
Mailing Address - Phone:913-696-1127
Mailing Address - Fax:
Practice Address - Street 1:9650 NALL AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66207-2952
Practice Address - Country:US
Practice Address - Phone:913-696-1127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-83534-031363LF0000X
KS146172163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse