Provider Demographics
NPI:1770121535
Name:PULLAM, BRIAN WADE
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WADE
Last Name:PULLAM
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:BRIAN
Other - Middle Name:
Other - Last Name:PULLAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN, APRN, FNP-C
Mailing Address - Street 1:1723 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4600
Mailing Address - Country:US
Mailing Address - Phone:850-368-4670
Mailing Address - Fax:
Practice Address - Street 1:4400 FL-20 SUITE #306
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-797-2598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11005354363LF0000X
FLAPRN11005354363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily