MEDICARE: SARAH ELIZABETH BULLARD RD LD

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
1	133V00000X	Registered Dietitian	2009035995	MO
2	133V00000X	Registered Dietitian	981995	MO

General Provider Information

NPI Number	:	1770147852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH ELIZABETH BULLARD RD LD

Provider Business Mailing Address
First Line	:	409 E LAKEWOOD ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-2531
Country	:	US
Telephone Number	:	660-238-3530
Fax Number	:

Provider Business Practice Location Address
First Line	:	409 E LAKEWOOD ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-2531
Country	:	US
Telephone Number	:	660-238-3530
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2019
Last Update Date	:	02/10/2026

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