Provider Demographics
NPI:1043910722
Name:PRUNTY, LAUREN ASHLEY
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:PRUNTY
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 1:450 E SAN JACINTO AVE
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-2833
Mailing Address - Country:US
Mailing Address - Phone:951-715-5040
Mailing Address - Fax:
Practice Address - Street 1:450 E SAN JACINTO AVE
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2833
Practice Address - Country:US
Practice Address - Phone:951-715-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CAMPSS-NMGJCU172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker