Healthcare Provider Details

I. General information

NPI: 1083275994
Provider Name (Legal Business Name): MRS. JESSICA PRUITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2019
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 E SILVER SPRINGS BLVD
OCALA FL
34470-6405
US

IV. Provider business mailing address

PO BOX 2066
LECANTO FL
34460-2066
US

V. Phone/Fax

Practice location:
  • Phone: 352-629-7336
  • Fax:
Mailing address:
  • Phone: 352-563-0931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06190737
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: