Healthcare Provider Details

I. General information

NPI: 1013841915
Provider Name (Legal Business Name): SAMUEL PULLEN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 DR TT LEWIS CIR
CHARLESTON MS
38921-2400
US

IV. Provider business mailing address

254 COUNTY ROAD 10
TILLATOBA MS
38961-2749
US

V. Phone/Fax

Practice location:
  • Phone: 662-607-5529
  • Fax:
Mailing address:
  • Phone: 662-607-5529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06260549
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: