Provider Demographics
NPI:1588426340
Name:PULLEN, SAMANTHA RUTH
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RUTH
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 1:2211 JOY RD
Mailing Address - Street 2:
Mailing Address - City:OCCIDENTAL
Mailing Address - State:CA
Mailing Address - Zip Code:95465-9259
Mailing Address - Country:US
Mailing Address - Phone:408-529-0289
Mailing Address - Fax:
Practice Address - Street 1:1435 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2847
Practice Address - Country:US
Practice Address - Phone:415-459-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41990225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist