Basic Information
| Provider Information | |||||||||
| NPI: | 1518255371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRUITT | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C, RN, MSN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAY | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 982 CHAMBERS ST | ||||||||
| Address2: | OGDEN VA CBOC | ||||||||
| City: | SOUTH OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 982 CHAMBERS ST | ||||||||
| Address2: | OGDEN VA CBOC | ||||||||
| City: | SOUTH OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 01/02/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 28164118A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.