Provider Demographics
NPI:1124175682
Name:PRUITT, LISA A
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
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 1:1017 STONE ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-3179
Mailing Address - Country:US
Mailing Address - Phone:419-656-7348
Mailing Address - Fax:
Practice Address - Street 1:1017 STONE ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3179
Practice Address - Country:US
Practice Address - Phone:419-656-7348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide