Provider Demographics
NPI:1790409928
Name:BULLARD, EMILY (PTA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 PLEASANT PLAINS EXT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6087
Mailing Address - Country:US
Mailing Address - Phone:731-984-7098
Mailing Address - Fax:731-300-4405
Practice Address - Street 1:2075 PLEASANT PLAINS EXT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6087
Practice Address - Country:US
Practice Address - Phone:731-984-7098
Practice Address - Fax:731-300-4405
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5877208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation