Provider Demographics
NPI:1306006127
Name:BULLARD, ANISSA EMANUEL
Entity Type:Individual
Prefix:MRS
First Name:ANISSA
Middle Name:EMANUEL
Last Name:BULLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 NC HWY 211 WEST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28360-3696
Mailing Address - Country:US
Mailing Address - Phone:910-735-0500
Mailing Address - Fax:910-735-0200
Practice Address - Street 1:1548 NC HIGHWAY 211 W
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28360-3696
Practice Address - Country:US
Practice Address - Phone:910-735-0500
Practice Address - Fax:910-735-0200
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC1961251E00000X, 253Z00000X
NC00982332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCAP3409271Medicaid
NC7705295Medicaid
NC3419206Medicaid
NCPCS6600738Medicaid