Provider Demographics
NPI:1568714210
Name:PULLEN, STACEY LYNN (NP-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:PULLEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:14 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-4381
Practice Address - Country:US
Practice Address - Phone:770-749-9600
Practice Address - Fax:770-749-9628
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN174219363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003128807AMedicaid
GA202I501207Medicare PIN