Basic Information
| Provider Information | |||||||||
| NPI: | 1720017395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRUGH | ||||||||
| FirstName: | SALLIE | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 MEDICAL PARK RD | ||||||||
| Address2: | SUITE 200A | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034347950 | ||||||||
| FaxNumber: | 8034348606 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034347950 | ||||||||
| FaxNumber: | 8034348606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | APN2421 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | NP0311 | 05 | SC | MEDICAID |