Healthcare Provider Details

I. General information

NPI: 1114304284
Provider Name (Legal Business Name): ROSEANN PRUITT PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 03/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1762 CLIFTON RD NE STE 1650
ATLANTA GA
30322-4001
US

IV. Provider business mailing address

169 REDTAIL RD
JEFFERSON GA
30549-7070
US

V. Phone/Fax

Practice location:
  • Phone: 978-618-7329
  • Fax:
Mailing address:
  • Phone: 978-618-7329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9174
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001944
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: