Provider Demographics
NPI:1497374763
Name:BULL, LYNEA IBIDUN
Entity Type:Individual
Prefix:
First Name:LYNEA
Middle Name:IBIDUN
Last Name:BULL
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 1:531 ASBURY CIR STE N340
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1006
Mailing Address - Country:US
Mailing Address - Phone:404-778-5975
Mailing Address - Fax:
Practice Address - Street 1:1364 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-3411
Practice Address - Country:US
Practice Address - Phone:404-778-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA95866207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program