Provider Demographics
NPI:1144198227
Name:PRUITT, DUSTIN LEE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LEE
Last Name:PRUITT
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 EDGEMONT
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-3824
Mailing Address - Country:US
Mailing Address - Phone:619-948-5934
Mailing Address - Fax:
Practice Address - Street 1:14 EDGEMONT
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-3824
Practice Address - Country:US
Practice Address - Phone:619-948-5934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-29
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036000363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care