Basic Information
| Provider Information | |||||||||
| NPI: | 1336190487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRUNTY | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 WASHINTON HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056618715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028885688 | ||||||||
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| Practice Location | |||||||||
| Address1: | 609 WASHINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056618652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028885688 | ||||||||
| FaxNumber: | 8028886818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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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 | 2084N0400X | 042-0008373 | VT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0VN0112 | 05 | VT | MEDICAID | 00018146 | 01 | VT | BCBS | OTHER |