Provider Demographics
NPI:1114303245
Name:PULLYBLANK, KEVIN (AT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PULLYBLANK
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3193 JANE ST
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14423-1024
Mailing Address - Country:US
Mailing Address - Phone:585-944-9277
Mailing Address - Fax:
Practice Address - Street 1:3193 JANE ST
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:NY
Practice Address - Zip Code:14423-1024
Practice Address - Country:US
Practice Address - Phone:585-944-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0044502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer