Provider Demographics
NPI:1255903779
Name:BULLARD, RICHARD S (APRN)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:BULLARD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 PITTWICK LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7003
Mailing Address - Country:US
Mailing Address - Phone:386-517-4103
Mailing Address - Fax:352-273-5683
Practice Address - Street 1:45 PITTWICK LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7003
Practice Address - Country:US
Practice Address - Phone:386-517-4103
Practice Address - Fax:386-241-1022
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014272363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner