Provider Demographics
NPI:1366961104
Name:PRUETT, JULIANNE JOY (PA)
Entity type:Individual
Prefix:
First Name:JULIANNE
Middle Name:JOY
Last Name:PRUETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JULIANNE
Other - Middle Name:JOY
Other - Last Name:KUCERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4780 N JOSEY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4615
Mailing Address - Country:US
Mailing Address - Phone:972-492-1334
Mailing Address - Fax:
Practice Address - Street 1:4780 N JOSEY LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4615
Practice Address - Country:US
Practice Address - Phone:972-492-1334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11554363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant