Healthcare Provider Details

I. General information

NPI: 1518875913
Provider Name (Legal Business Name): STEPHANIE ANNETTE PRUETT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E PRIMROSE ST
SPRINGFIELD MO
65804-7929
US

IV. Provider business mailing address

5265 S MICHIGAN AVE APT E101
SPRINGFIELD MO
65810-3005
US

V. Phone/Fax

Practice location:
  • Phone: 417-885-4700
  • Fax:
Mailing address:
  • Phone: 417-306-4727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number121029
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: