Provider Demographics
NPI:1063453371
Name:PULLEN, PHYLLIS ARLENE (CRNA, RETIRED)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ARLENE
Last Name:PULLEN
Suffix:
Gender:F
Credentials:CRNA, RETIRED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 RHODA ST
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-1411
Mailing Address - Country:US
Mailing Address - Phone:304-542-5402
Mailing Address - Fax:
Practice Address - Street 1:314 RHODA ST
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526
Practice Address - Country:US
Practice Address - Phone:304-542-5402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13723367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV270052997002OtherTRICARE
WVP00001155OtherRR MEDICARE
WV27005299700OtherWORKERS COMP
WV0068871000Medicaid
WV0207026000Medicaid
WV001713623OtherBCBS
WV27005299700OtherBRICKSTREET
WV270052997006OtherTRICARE
WVDA0096OtherRR MEDICARE
WV001706470OtherMSBCBS GROUP
WV8219822Medicare PIN
WV9333201Medicare PIN