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NPI Code Detail

MEDICARE: MRS. KELLY MICHELLE BULLOCK CRNA

MEDICARE: MRS. KELLY MICHELLE BULLOCK CRNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse Anesthetist5919NC
2367500000XCertified Registered Nurse Anesthetist121741NC
3367500000XCertified Registered Nurse Anesthetist0024181581VA

General Provider Information

NPI Number : 1720572225
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KELLY MICHELLE BULLOCK CRNA
Provider Business Mailing Address
First Line : 100 KIMEL FOREST DR
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27103-6074
Country : US
Telephone Number : 336-716-2255
Fax Number :
Provider Business Practice Location Address
First Line : 1901 TATE SPRINGS RD
Second Line :
City : LYNCHBURG
State : VA
Zip : 24501-1109
Country : US
Telephone Number : 704-942-4854
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/18/2018
Last Update Date : 03/03/2026

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