Provider Demographics
NPI:1386708691
Name:PRUITT, STACY LYNN (RD, LD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:PRUITT
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 BRADFORD DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-1610
Mailing Address - Country:US
Mailing Address - Phone:409-866-9622
Mailing Address - Fax:
Practice Address - Street 1:3030 NORTH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1433
Practice Address - Country:US
Practice Address - Phone:409-892-2111
Practice Address - Fax:409-813-3848
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07468133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered