Provider Demographics
NPI:1588308068
Name:PRUITT- GARNER, MARIE ANTIONETTE (LPN)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANTIONETTE
Last Name:PRUITT- GARNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-1563
Mailing Address - Country:US
Mailing Address - Phone:216-854-2857
Mailing Address - Fax:
Practice Address - Street 1:4607 E 104TH ST
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-1563
Practice Address - Country:US
Practice Address - Phone:216-854-2857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH185068164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse