Provider Demographics
NPI:1053876391
Name:PRUITT, SAMANTHA (PMHNP-BC, FNP-BC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PMHNP-BC, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 CREEKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3732
Mailing Address - Country:US
Mailing Address - Phone:404-421-2089
Mailing Address - Fax:
Practice Address - Street 1:228 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3732
Practice Address - Country:US
Practice Address - Phone:404-421-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN257993363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily