Provider Demographics
NPI:1033463880
Name:BULLARD, TRACEY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13523 HERNDON OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42262-9369
Mailing Address - Country:US
Mailing Address - Phone:270-839-9697
Mailing Address - Fax:
Practice Address - Street 1:13523 HERNDON OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:KY
Practice Address - Zip Code:42262-9369
Practice Address - Country:US
Practice Address - Phone:270-839-9697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007747364SE0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency