Provider Demographics
NPI:1962899195
Name:PRUNTY, CALLY MARIE (MD)
Entity type:Individual
Prefix:
First Name:CALLY
Middle Name:MARIE
Last Name:PRUNTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3955 PARKLAWN AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5660
Mailing Address - Country:US
Mailing Address - Phone:952-831-4454
Mailing Address - Fax:952-278-6947
Practice Address - Street 1:3955 PARKLAWN AVE STE 120
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5660
Practice Address - Country:US
Practice Address - Phone:952-831-4454
Practice Address - Fax:952-278-6947
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2020-09-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN63079208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics