Provider Demographics
NPI:1396191888
Name:BULLARD, NIDIA (CPNP)
Entity Type:Individual
Prefix:
First Name:NIDIA
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 STATION PLZ N STE 611
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3893
Mailing Address - Country:US
Mailing Address - Phone:516-292-1034
Mailing Address - Fax:516-292-0565
Practice Address - Street 1:175 FULTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-3702
Practice Address - Country:US
Practice Address - Phone:516-292-1034
Practice Address - Fax:516-292-0565
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF382580363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics