Provider Demographics
NPI:1669710687
Name:BULLARD, SUSAN GIBBS (RN, PHN)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:GIBBS
Last Name:BULLARD
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14215 ROAD 28
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-5729
Mailing Address - Country:US
Mailing Address - Phone:559-675-4945
Mailing Address - Fax:559-675-7983
Practice Address - Street 1:14215 ROAD 28
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-5729
Practice Address - Country:US
Practice Address - Phone:559-662-8314
Practice Address - Fax:559-675-7983
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN492295163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health