Provider Demographics
NPI:1154310902
Name:MOORE-PULLIN, MOLLY ANNE (ANP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANNE
Last Name:MOORE-PULLIN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:A
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5874
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:802 AINSWORTH DR STE A
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1623
Practice Address - Country:US
Practice Address - Phone:928-445-6025
Practice Address - Fax:928-777-2423
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN049339363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ214401OtherMEDICARE INDIVIDUAL PTAN
S84475Medicare UPIN
AZZ28062Medicare PIN
AZP00464602Medicare PIN
TN1035070I57OtherMEDICARE PTAN
AZZ28061Medicare PIN
AZZ28061Medicare PIN