Provider Demographics
NPI:1174575864
Name:PRUETT, JULIE (NP)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:
Last Name:PRUETT
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:NEOPLASTIC DISEASES
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8927
Mailing Address - Fax:414-805-6815
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:NEOPLASTIC DISEASES
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8927
Practice Address - Fax:414-805-6815
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI148831163W00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
039906261MOtherHUMANA
WI1174575864Medicaid
WI025R73601Medicare PIN
039906261MOtherHUMANA