Provider Demographics
NPI:1962488361
Name:WYNN BULLARD, MELLORYA LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:MELLORYA
Middle Name:LYNN
Last Name:WYNN BULLARD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 N DREW ST
Mailing Address - Street 2:
Mailing Address - City:STAR CITY
Mailing Address - State:AR
Mailing Address - Zip Code:71667-5730
Mailing Address - Country:US
Mailing Address - Phone:501-231-8296
Mailing Address - Fax:870-628-3221
Practice Address - Street 1:904 N DREW ST
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667-5730
Practice Address - Country:US
Practice Address - Phone:870-628-3888
Practice Address - Fax:870-628-3221
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1640111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q41710Medicare UPIN
AR5Y222Medicare ID - Type Unspecified