Provider Demographics
NPI:1851729891
Name:BULLARD, KOREY
Entity Type:Individual
Prefix:MRS
First Name:KOREY
Middle Name:
Last Name:BULLARD
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 1:1365 E PARKS HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8297
Mailing Address - Country:US
Mailing Address - Phone:907-982-9370
Mailing Address - Fax:
Practice Address - Street 1:1365 E PARKS HWY STE 202
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8297
Practice Address - Country:US
Practice Address - Phone:907-982-9370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist