Provider Demographics
NPI:1629378948
Name:BULLARD LANE, MARY ALICE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:BULLARD LANE
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:PO BOX 160718
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-0718
Mailing Address - Country:US
Mailing Address - Phone:407-862-7632
Mailing Address - Fax:407-862-8739
Practice Address - Street 1:530 YEW CT
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-1459
Practice Address - Country:US
Practice Address - Phone:407-862-7632
Practice Address - Fax:407-862-8739
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL688942598172V00000X
FL688942596172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker