Provider Demographics
NPI:1447016373
Name:PULLIAM, DEAUDRA (LPN)
Entity type:Individual
Prefix:
First Name:DEAUDRA
Middle Name:
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:DEAUDRA
Other - Middle Name:
Other - Last Name:PULLIAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:4157 HALE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-2557
Mailing Address - Country:US
Mailing Address - Phone:615-497-6906
Mailing Address - Fax:
Practice Address - Street 1:4157 HALE AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-2557
Practice Address - Country:US
Practice Address - Phone:615-497-6906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN94689164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse