Provider Demographics
NPI:1942017157
Name:PRUITT, ABIGAIL JAIDEN LEREA
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:JAIDEN LEREA
Last Name:PRUITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 NECTAR DR OOZLEY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:BRADSHAW
Mailing Address - State:WV
Mailing Address - Zip Code:24817
Mailing Address - Country:US
Mailing Address - Phone:336-413-9831
Mailing Address - Fax:
Practice Address - Street 1:53 NECTAR DR OOZLEY HOLLOW RD
Practice Address - Street 2:
Practice Address - City:BRADSHAW
Practice Address - State:WV
Practice Address - Zip Code:24817
Practice Address - Country:US
Practice Address - Phone:336-413-9831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant