Provider Demographics
NPI:1871737254
Name:PRUITT, KELLEY JEAN (CNS, FNP)
Entity type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:JEAN
Last Name:PRUITT
Suffix:
Gender:F
Credentials:CNS, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1112
Mailing Address - Street 2:
Mailing Address - City:ELECTRA
Mailing Address - State:TX
Mailing Address - Zip Code:76360-1112
Mailing Address - Country:US
Mailing Address - Phone:940-495-3981
Mailing Address - Fax:
Practice Address - Street 1:405 SE ACCESS RD
Practice Address - Street 2:
Practice Address - City:IOWA PARK
Practice Address - State:TX
Practice Address - Zip Code:76367-6985
Practice Address - Country:US
Practice Address - Phone:940-592-3500
Practice Address - Fax:940-592-4342
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX602154363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily