Healthcare Provider Details

I. General information

NPI: 1154237675
Provider Name (Legal Business Name): MRS. STACIE ARDELLA PRUITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

884 SE BROOKSIDE DR
TOPEKA KS
66607-2324
US

IV. Provider business mailing address

884 SE BROOKSIDE DR
TOPEKA KS
66607-2324
US

V. Phone/Fax

Practice location:
  • Phone: 785-408-3507
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number13-138824-092
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: