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General NPI Number Information
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NPI Number | 1114304284
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Entity Type | Individual
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Provider Name | ROSEANN PRUITT PA-C, ATC
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Gender | Female
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Dates
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Enumeration Date | 04/28/2015
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Last Update Date | 03/10/2019
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Provider Practice Location Address
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Address Line | 1762 CLIFTON RD NE STE 1650
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City | ATLANTA
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State | GA
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Zip | 30322-4001
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Country | US
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Telephone | 978-618-7329
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Fax |
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Provider Business Mailing Address
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Address Line | 169 REDTAIL RD
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City | JEFFERSON
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State | GA
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Zip | 30549-7070
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Country | US
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Telephone | 978-618-7329
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT001944
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 9174
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License Number State | GA
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