Provider Demographics
NPI:1912089905
Name:PRUITT, MOLLY C (FNP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:C
Last Name:PRUITT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:C
Other - Last Name:LINDGREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:760-827-7530
Mailing Address - Fax:
Practice Address - Street 1:2176 SALK AVE
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008
Practice Address - Country:US
Practice Address - Phone:760-827-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20591363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN286995100Medicaid
B691OtherCHAMPUS
MT4306939Medicaid
IA0598623Medicaid
Q55249Medicare UPIN
MN286995100Medicaid
WI41272200Medicare ID - Type UnspecifiedWI MA