Healthcare Provider Details

I. General information

NPI: 1386708691
Provider Name (Legal Business Name): STACY LYNN PRUITT RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 NORTH ST SUITE 201
BEAUMONT TX
77702-1433
US

IV. Provider business mailing address

390 BRADFORD DR
BEAUMONT TX
77707-1610
US

V. Phone/Fax

Practice location:
  • Phone: 409-892-2111
  • Fax: 409-813-3848
Mailing address:
  • Phone: 409-866-9622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT07468
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: