MEDICARE: MR. CRAIG PRUITT REGISTERED NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	RN60760255	WA

General Provider Information

NPI Number	:	1659099828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CRAIG PRUITT REGISTERED NURSE

Provider Business Mailing Address
First Line	:	1415 COMMERCIAL AVE # 158
Second Line	:
City	:	ANACORTES
State	:	WA
Zip	:	98221-2232
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	275 NE 10TH AVE
Second Line	:
City	:	OAK HARBOR
State	:	WA
Zip	:	98277-2232
Country	:	US
Telephone Number	:	425-341-1871
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2022
Last Update Date	:	08/15/2022

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