Healthcare Provider Details

I. General information

NPI: 1184878373
Provider Name (Legal Business Name): DEANNA M PRUITT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 SPRUCE ST
ELLIS KS
67637-1757
US

IV. Provider business mailing address

619 S IOWA ST
KANOPOLIS KS
67454-9545
US

V. Phone/Fax

Practice location:
  • Phone: 615-896-6400
  • Fax:
Mailing address:
  • Phone: 615-896-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1400978
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: