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1750515649

NPI Code Detail

MEDICARE: SANDRA L PRUETT CNP

MEDICARE: SANDRA L PRUETT CNP

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	163W00000X	Registered Nurse	L1-0017162	DE
2	363LA2200X	Adult Health Nurse Practitioner	LB-0000225	DE
3	363LA2200X	Adult Health Nurse Practitioner	AC001270	MD
4	363LA2200X	Adult Health Nurse Practitioner	GAA-NP000964	GA

General Provider Information

NPI Number	:	1750515649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA L PRUETT CNP

Provider Business Mailing Address
First Line	:	55 WHITCHER ST NE STE 160
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-1160
Country	:	US
Telephone Number	:	770-590-4180
Fax Number	:	770-590-4186

Provider Business Practice Location Address
First Line	:	55 WHITCHER ST NE STE 160
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-1160
Country	:	US
Telephone Number	:	770-590-4180
Fax Number	:	770-590-4186

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

Provider Enumeration Date	:	05/07/2009
Last Update Date	:	11/14/2022

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Directions to “ SANDRA L PRUETT CNP” Practice Location

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