Provider Demographics
NPI:1689138414
Name:PULLIAM, GLENISHIA K
Entity Type:Individual
Prefix:
First Name:GLENISHIA
Middle Name:K
Last Name:PULLIAM
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 1:3300 GORDON DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2657
Mailing Address - Country:US
Mailing Address - Phone:804-721-0758
Mailing Address - Fax:
Practice Address - Street 1:3300 GORDON DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2657
Practice Address - Country:US
Practice Address - Phone:804-721-0758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT62511423347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle