Healthcare Provider Details

I. General information

NPI: 1356658322
Provider Name (Legal Business Name): ALFREDIA PRUITT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4499 BEACON HILL DR SW
LILBURN GA
30047-8913
US

IV. Provider business mailing address

4499 BEACON HILL DR SW
LILBURN GA
30047-8913
US

V. Phone/Fax

Practice location:
  • Phone: 770-668-3915
  • Fax:
Mailing address:
  • Phone: 770-668-3915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: