MEDICARE: ELLEN G PRUNEAU

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	152W00000X	Optometrist	OPT.007079	OH

General Provider Information

NPI Number	:	1710625223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN G PRUNEAU

Provider Business Mailing Address
First Line	:	1550 LONDON AVE
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-8988
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 LONDON AVE
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-8988
Country	:	US
Telephone Number	:	937-553-2020
Fax Number	:

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

Provider Enumeration Date	:	05/24/2022
Last Update Date	:	04/01/2025

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Directions to “ ELLEN G PRUNEAU ” Practice Location

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