=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801615349
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIANNE FRANCES PULLAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2024
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 533 VICOT WAY UNIT H
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80524-4990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-214-7550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 533 VICOT WAY UNIT H
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80524-4990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-214-7550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0400X
-----------------------------------------------------
Taxonomy Name | Case Management Registered Nurse
-----------------------------------------------------
License Number | 0082523
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------