Healthcare Provider Details

I. General information

NPI: 1982496758
Provider Name (Legal Business Name): LISA ROSCHELLE PRUITT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W BRAKER LN
AUSTIN TX
78758-3801
US

IV. Provider business mailing address

1210 W BRAKER LN
AUSTIN TX
78758-3801
US

V. Phone/Fax

Practice location:
  • Phone: 512-978-8613
  • Fax: 512-978-8613
Mailing address:
  • Phone: 512-978-8613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number703172
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number703172
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number703172
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: