MEDICARE: MOLLY C PRUITT FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	814191	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	B691	OTHER	CHAMPUS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912089905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY C PRUITT FNP

Provider Business Mailing Address
First Line	:	12130 HERMESA COLINA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-1137
Country	:	US
Telephone Number	:	612-207-2801
Fax Number	:

Provider Business Practice Location Address
First Line	:	12130 HERMESA COLINA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-1137
Country	:	US
Telephone Number	:	612-207-2801
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	05/26/2026

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