Healthcare Provider Details

I. General information

NPI: 1235792177
Provider Name (Legal Business Name): ALEXA BREANNE PULLEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 11/20/2024
Certification Date: 11/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19239 DARBY RD
EAGLE RIVER AK
99577
US

IV. Provider business mailing address

12110 BUSINESS BLVD STE 6 PMB 189
EAGLE RIVER AK
99577-7798
US

V. Phone/Fax

Practice location:
  • Phone: 907-854-4482
  • Fax:
Mailing address:
  • Phone: 907-854-4482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number145169
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT86980
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number229812
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: