Provider Demographics
NPI:1093408254
Name:BULLOCK, AMY CAROLYN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:CAROLYN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:CAROLYN
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD/LD
Mailing Address - Street 1:18521 RASTRO DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9600
Mailing Address - Country:US
Mailing Address - Phone:405-596-9860
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF OKLAHOMA MEDICAL CENTER
Practice Address - Street 2:700 NORTH EAST 13TH STREET
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104
Practice Address - Country:US
Practice Address - Phone:405-271-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1238133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered