Provider Demographics
NPI:1487853255
Name:BULLARD, TAMRA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:TAMRA
Middle Name:MARIE
Last Name:BULLARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12052 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4969
Mailing Address - Country:US
Mailing Address - Phone:703-707-0706
Mailing Address - Fax:
Practice Address - Street 1:12052 N SHORE DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-4969
Practice Address - Country:US
Practice Address - Phone:703-707-0706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204920225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist