Provider Demographics
NPI:1104880210
Name:PRUETT, MEGAN CONSEDINE (CPNP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:CONSEDINE
Last Name:PRUETT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 N DRUID HILLS RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3117
Mailing Address - Country:US
Mailing Address - Phone:404-785-5437
Mailing Address - Fax:404-785-9111
Practice Address - Street 1:2220 N DRUID HILLS RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3117
Practice Address - Country:US
Practice Address - Phone:404-785-5437
Practice Address - Fax:404-785-9111
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170580363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA623071340AMedicaid