Individual
MRS. KRISTEN AGNEW PRUITT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.S, PT
Contact information
Practice address
4615 ENFIELD DR, GAINESVILLE, GA 30506-4663
(678) 450-1174
(678) 450-1174
Mailing address
4615 ENFIELD DR, GAINESVILLE, GA 30506-4663
(678) 450-1174
(678) 450-1174
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT004847
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10054142
AMERIGROUP PROVIDER #
GA
01
—
PT004847
PHYSICAL THERAPY LICENSE
GA
Enumeration date
10/04/2006
Last updated
07/09/2007
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