Healthcare Provider Details

I. General information

NPI: 1114975505
Provider Name (Legal Business Name): PRISCILLA ELIZABETH PULLIAM N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 RIVER OAKS DR
JACKSON MS
39232-9553
US

IV. Provider business mailing address

2500 NORTH STATE STREET JMM ROOM 2525
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-924-3719
  • Fax:
Mailing address:
  • Phone: 601-984-6426
  • Fax: 601-984-6439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number865613
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: