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General NPI Number Information
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NPI Number | 1659818904
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Entity Type | Individual
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Provider Name | SHANIKA SHANTA PRUITT FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 01/25/2017
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Last Update Date | 12/08/2021
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Provider Practice Location Address
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Address Line | 1400 LEMAY FERRY RD
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City | SAINT LOUIS
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State | MO
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Zip | 63125
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Country | US
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Telephone | 314-827-6868
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Fax | 314-627-4546
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Provider Business Mailing Address
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Address Line | 225 SAINT LOUIS AVE UNIT 11169
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City | SAINT LOUIS
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State | MO
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Zip | 63135-2783
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Country | US
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Telephone | 314-827-6868
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Fax | 314-627-4546
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2017000938
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License Number State | MO
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