Provider Demographics
NPI:1821689068
Name:PRUITT, ANNA DAVENPORT SHEALY (PA-C)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:DAVENPORT SHEALY
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:DAVENPORT
Other - Last Name:SHEALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4705 UNIVERSITY DR BLDG 700
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3489
Mailing Address - Country:US
Mailing Address - Phone:484-900-1317
Mailing Address - Fax:866-538-4716
Practice Address - Street 1:5821 FAIRVIEW RD STE 106
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3649
Practice Address - Country:US
Practice Address - Phone:704-826-3550
Practice Address - Fax:704-538-4135
Is Sole Proprietor?:No
Enumeration Date:2021-01-31
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12215363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program