Healthcare Provider Details

I. General information

NPI: 1679577555
Provider Name (Legal Business Name): KATHRYN CLAIRE PRUITT APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CHASE ST
BYHALIA MS
38611
US

IV. Provider business mailing address

8820 TURKEY CREEK DR
OLIVE BRANCH MS
38654-8096
US

V. Phone/Fax

Practice location:
  • Phone: 502-810-4164
  • Fax:
Mailing address:
  • Phone: 502-810-4164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19930
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number895684
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: