Healthcare Provider Details

I. General information

NPI: 1568223782
Provider Name (Legal Business Name): KAYLA PRUITT CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 SARDIS DR
BOAZ AL
35956-2139
US

IV. Provider business mailing address

1180 SARDIS DR
BOAZ AL
35956-2139
US

V. Phone/Fax

Practice location:
  • Phone: 256-613-6070
  • Fax:
Mailing address:
  • Phone: 256-593-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-157724
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: