Healthcare Provider Details

I. General information

NPI: 1376454033
Provider Name (Legal Business Name): ALYSSA PRUETT
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E HOWARD ST
DRIGGS ID
83422-5112
US

IV. Provider business mailing address

120 E HOWARD ST
DRIGGS ID
83422-5112
US

V. Phone/Fax

Practice location:
  • Phone: 844-617-7254
  • Fax: 855-802-2795
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number48880
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: