Healthcare Provider Details

I. General information

NPI: 1043559529
Provider Name (Legal Business Name): FLORTASHA LARAY PULLOM FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 ROCKBRIDGE RD STE 15B
STONE MOUNTAIN GA
30087-3306
US

IV. Provider business mailing address

PO BOX 740015
ATLANTA GA
30374-0015
US

V. Phone/Fax

Practice location:
  • Phone: 470-444-3134
  • Fax: 470-276-4370
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP331904
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201141801RN
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN331904
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2018017288
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: