Healthcare Provider Details

I. General information

NPI: 1295665453
Provider Name (Legal Business Name): ROBERT ALAN PRUETT III AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DR STE 110
FORT WAYNE IN
46845-1673
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6780
  • Fax: 260-425-6789
Mailing address:
  • Phone: 260-668-0033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71018191A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: