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General NPI Number Information
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NPI Number | 1689138414
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Entity Type | Individual
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Provider Name | GLENISHIA K PULLIAM
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Gender | Female
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Dates
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Enumeration Date | 01/25/2019
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Last Update Date | 01/25/2019
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Provider Practice Location Address
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Address Line | 3300 GORDON DR
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City | PETERSBURG
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State | VA
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Zip | 23805-2657
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Country | US
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Telephone | 804-721-0758
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Fax |
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Provider Business Mailing Address
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Address Line | 3300 GORDON DR
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City | PETERSBURG
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State | VA
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Zip | 23805-2657
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Country | US
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Telephone | 804-721-0758
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number | T62511423
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License Number State | VA
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