Provider Demographics
NPI:1235792177
Name:PULLEN, ALEXA BREANNE (NUTRITIONIST)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:BREANNE
Last Name:PULLEN
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2271 W RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-5331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3161 E PALMER WASILLA HWY STE 1C
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7271
Practice Address - Country:US
Practice Address - Phone:907-357-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK145169133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist