Basic Information
| Provider Information | |||||||||
| NPI: | 1306054341 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRUITT | ||||||||
| FirstName: | TIFFANY | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712B SAINT JOHN ST | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678465128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202751766 | ||||||||
| FaxNumber: | 2752754729 | ||||||||
| Practice Location | |||||||||
| Address1: | 712B SAINT JOHN ST | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678465128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202751766 | ||||||||
| FaxNumber: | 2752754729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 13-91395-121 | KS | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 13-91395-121 | 01 | KS | KANSAS STATE BOARD OF NUR | OTHER |