Provider Demographics
NPI:1255534210
Name:PRUITT, STEPHANIE MARIE (ATC, LAT)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 MUSCOVY CIR
Mailing Address - Street 2:APT. F
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-1496
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:421 WOODLAND BLVD
Practice Address - Street 2:UNIT 8317
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32723-0001
Practice Address - Country:US
Practice Address - Phone:386-822-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 18182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer