Provider Demographics
NPI:1366698409
Name:PRUITT, LAVONNE (FNP)
Entity type:Individual
Prefix:
First Name:LAVONNE
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 VALLEY VIEW BLVD NW
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-2040
Mailing Address - Country:US
Mailing Address - Phone:540-362-0360
Mailing Address - Fax:
Practice Address - Street 1:4910 VALLEY VIEW BLVD NW
Practice Address - Street 2:SUITE 310
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-2040
Practice Address - Country:US
Practice Address - Phone:540-362-0360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167925363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily