Provider Demographics
NPI:1720572225
Name:BULLOCK, KELLY MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MICHELLE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:MICHELLE
Other - Last Name:HENION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 SEDGEWICK DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-3336
Mailing Address - Country:US
Mailing Address - Phone:704-942-4854
Mailing Address - Fax:
Practice Address - Street 1:1901 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1109
Practice Address - Country:US
Practice Address - Phone:704-942-4854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC121741367500000X
VA0024181581367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered