Provider Demographics
NPI:1336918309
Name:PRUITT, ANGELA (CHW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:CHW
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 301
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48826-0301
Mailing Address - Country:US
Mailing Address - Phone:888-305-8355
Mailing Address - Fax:517-485-7581
Practice Address - Street 1:809 CENTER ST STE 7B
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-5257
Practice Address - Country:US
Practice Address - Phone:888-305-8355
Practice Address - Fax:517-485-7581
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker