Healthcare Provider Details

I. General information

NPI: 1356336812
Provider Name (Legal Business Name): TAMMY G PRUSE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3874 HIGHWAY 90 STE 101
PACE FL
32571-1014
US

IV. Provider business mailing address

PO BOX 95590
SOUTH JORDAN UT
84095-0590
US

V. Phone/Fax

Practice location:
  • Phone: 850-908-2315
  • Fax: 850-908-2307
Mailing address:
  • Phone: 801-352-9500
  • Fax: 801-352-7976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS 8320
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: