Provider Demographics
NPI:1407941057
Name:BULLOCK, KELLY LEIGH (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LEIGH
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 CHAROLAIS DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701
Mailing Address - Country:US
Mailing Address - Phone:402-379-1997
Mailing Address - Fax:
Practice Address - Street 1:106 E WAYNE ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NE
Practice Address - Zip Code:68771-5300
Practice Address - Country:US
Practice Address - Phone:402-337-0200
Practice Address - Fax:402-337-1020
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine