Provider Demographics
NPI:1285049254
Name:PRUITT, KELLI ELIZABETH
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:ELIZABETH
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 1:2969 CURRAN DR N
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4121
Mailing Address - Country:US
Mailing Address - Phone:601-540-5598
Mailing Address - Fax:
Practice Address - Street 1:2969 CURRAN DR N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4121
Practice Address - Country:US
Practice Address - Phone:601-540-5598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11007306363LF0000X, 363LP0808X
MSR883741363LP0808X, 363LF0000X
WAAP61401686363LP0808X
OR10006919363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07407051Medicaid