Provider Demographics
NPI:1285055921
Name:PULLIAM, LARRY L (RN)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:PULLIAM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2953 CIRCLING HAWK ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81503-8306
Mailing Address - Country:US
Mailing Address - Phone:970-623-2970
Mailing Address - Fax:
Practice Address - Street 1:2953 CIRCLING HAWK ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81503-8306
Practice Address - Country:US
Practice Address - Phone:970-623-2970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-24
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0175277163W00000X
SCRN.210725 R163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse