Provider Demographics
NPI:1659912731
Name:BULLARD, JENNIFER RENAE (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENAE
Last Name:BULLARD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18901 IDA MILL RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28351-8326
Mailing Address - Country:US
Mailing Address - Phone:910-462-2707
Mailing Address - Fax:
Practice Address - Street 1:18901 IDA MILL RD
Practice Address - Street 2:
Practice Address - City:LAUREL HILL
Practice Address - State:NC
Practice Address - Zip Code:28351-8326
Practice Address - Country:US
Practice Address - Phone:910-462-2707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57779363LF0000X
NC5014203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily