Provider Demographics
NPI:1407522063
Name:PULLER, KEA
Entity Type:Individual
Prefix:
First Name:KEA
Middle Name:
Last Name:PULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22050 EASTSIDE DR APT 254
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-7224
Mailing Address - Country:US
Mailing Address - Phone:304-261-4112
Mailing Address - Fax:
Practice Address - Street 1:22050 EASTSIDE DR APT 254
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-7224
Practice Address - Country:US
Practice Address - Phone:304-261-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker