Basic Information
| Provider Information | |||||||||
| NPI: | 1326670175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUITT | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | MARIE | ||||||||
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| OtherLastName: | TRUITT | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 304 WOLF RUN RD | ||||||||
| Address2: | |||||||||
| City: | WEST PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456639031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403579696 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 115 PRIVATE ROAD 977 | ||||||||
| Address2: | |||||||||
| City: | PEDRO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456598608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405341386 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2020 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN.173525.MEDS-IV | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.