Provider Demographics
NPI:1669216479
Name:PRUITT, SHAWNA
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 E EL PASO AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2806
Mailing Address - Country:US
Mailing Address - Phone:559-283-5235
Mailing Address - Fax:
Practice Address - Street 1:2615 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2223
Practice Address - Country:US
Practice Address - Phone:559-836-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA663174163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management