Provider Demographics
NPI:1487713525
Name:PULLIAM, ALISE R (MPA, RD)
Entity type:Individual
Prefix:
First Name:ALISE
Middle Name:R
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:MPA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3352 STAR CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-0904
Mailing Address - Country:US
Mailing Address - Phone:757-535-1274
Mailing Address - Fax:
Practice Address - Street 1:6320 N CENTER DR
Practice Address - Street 2:BLDG #15 SUITE 140
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4009
Practice Address - Country:US
Practice Address - Phone:757-466-9446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered