1104571090 NPI number — DEWAYNE PRUITT RN, BSN

Table of content: DEWAYNE PRUITT RN, BSN (NPI 1104571090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104571090 NPI number — DEWAYNE PRUITT RN, BSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUITT
Provider First Name:
DEWAYNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, BSN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104571090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2111 JENKINS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALICEVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35442-4931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-367-1619
Provider Business Mailing Address Fax Number:
205-367-1619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2153 JENKINS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALICEVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-367-1619
Provider Business Practice Location Address Fax Number:
205-367-1619
Provider Enumeration Date:
02/18/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WH0200X , with the licence number:  1-121419 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000000000000 . This is a "DONT HAVE ONE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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