Provider Demographics
NPI:1033505524
Name:PRUITT, AMANDA KINNEY (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KINNEY
Last Name:PRUITT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:KINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2430 REIDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-3652
Mailing Address - Country:US
Mailing Address - Phone:864-516-1783
Mailing Address - Fax:864-594-0040
Practice Address - Street 1:2430 REIDVILLE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-3652
Practice Address - Country:US
Practice Address - Phone:864-516-1783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC51900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC519004Medicaid
SCSCF2976067OtherMEDICARE PIN
SCSCD3684862OtherMEDICARE
SCSCF2976121OtherMEDICARE PIN
SCSCF2976084OtherMEDICARE PIN
SCSCD368J577OtherMEDICARE PIN