Provider Demographics
NPI:1750515649
Name:PRUETT, SANDRA L (CNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:PRUETT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:55 WHITCHER ST NE STE 160
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1160
Mailing Address - Country:US
Mailing Address - Phone:770-590-4180
Mailing Address - Fax:770-590-4186
Practice Address - Street 1:55 WHITCHER ST NE STE 160
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1160
Practice Address - Country:US
Practice Address - Phone:770-590-4180
Practice Address - Fax:770-590-4186
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEL1-0017162163W00000X
DELB-0000225363LA2200X
MDAC001270363LA2200X
GAGAA-NP000964363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse