Provider Demographics
NPI:1386140614
Name:PRUETT, ADAM (RDN)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:PRUETT
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5116 EAGLE WING CT
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-4043
Mailing Address - Country:US
Mailing Address - Phone:636-584-9153
Mailing Address - Fax:
Practice Address - Street 1:5900 BOND AVE
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62207-2326
Practice Address - Country:US
Practice Address - Phone:618-332-5458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008029468133V00000X
IL164.007263133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered