Healthcare Provider Details

I. General information

NPI: 1114654852
Provider Name (Legal Business Name): CHARMAINE BULLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/03/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 OAKS WAY #904
POMPANO BEACH FL
33069
US

IV. Provider business mailing address

3890 SW 64TH AVE APT 314
DAVIE FL
33314-2592
US

V. Phone/Fax

Practice location:
  • Phone: 305-807-1909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: