Provider Demographics
NPI:1801643358
Name:PULLIAM, MCKENZIE RAQUEL (APRN)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:RAQUEL
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:RAQUEL
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3841 PIPER ST STE T100
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4674
Mailing Address - Country:US
Mailing Address - Phone:907-561-3211
Mailing Address - Fax:
Practice Address - Street 1:3841 PIPER ST STE T100
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4674
Practice Address - Country:US
Practice Address - Phone:907-561-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK222425363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care