Healthcare Provider Details

I. General information

NPI: 1447527429
Provider Name (Legal Business Name): KRISTIE K PRUNO CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2011
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 CRANSTON CROSSING PL
INDIAN TRAIL NC
28079-3697
US

IV. Provider business mailing address

2000 CRANSTON CROSSING PL
INDIAN TRAIL NC
28079-3697
US

V. Phone/Fax

Practice location:
  • Phone: 920-209-0845
  • Fax:
Mailing address:
  • Phone: 920-209-0845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4959
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12018
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA11813
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: