Provider Demographics
NPI:1982496758
Name:PRUITT, LISA ROSCHELLE (RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ROSCHELLE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 W BRAKER LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-3801
Mailing Address - Country:US
Mailing Address - Phone:512-978-8613
Mailing Address - Fax:
Practice Address - Street 1:1210 W BRAKER LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-3801
Practice Address - Country:US
Practice Address - Phone:512-978-8613
Practice Address - Fax:512-978-8613
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX703172163WW0101X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory