Provider Demographics
NPI:1336190487
Name:PRUNTY, JEAN M (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:PRUNTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 WASHINTON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-8715
Mailing Address - Country:US
Mailing Address - Phone:802-888-5688
Mailing Address - Fax:
Practice Address - Street 1:609 WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-8652
Practice Address - Country:US
Practice Address - Phone:802-888-5688
Practice Address - Fax:802-888-6818
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00083732084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0112Medicaid
VT00018146OtherBCBS
VTVN0112Medicare ID - Type Unspecified
VT00018146OtherBCBS