Provider Demographics
NPI:1629132295
Name:PULLEN, MARY ALICE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:PULLEN
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 1:1 N WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-9412
Mailing Address - Country:US
Mailing Address - Phone:304-733-1666
Mailing Address - Fax:
Practice Address - Street 1:5170 U.S. ROUTE 60 EAST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705
Practice Address - Country:US
Practice Address - Phone:304-399-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006340Medicaid