=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629845581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAVANNAH ADDISON PRUDEN AGNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2023
-----------------------------------------------------
Last Update Date | 11/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4420 LAKE BOONE TRL
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27607-7505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-784-7110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7416 CAPULIN CREST DR
-----------------------------------------------------
City | APEX
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27539-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-202-4876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 5023076
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 5023076
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------