Healthcare Provider Details

I. General information

NPI: 1407601420
Provider Name (Legal Business Name): KELLY PULLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 LANCASTER DR NE
SALEM OR
97305-1297
US

IV. Provider business mailing address

1260 COLGAN CT SE
SALEM OR
97302-1720
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201341443RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: