Healthcare Provider Details

I. General information

NPI: 1699353326
Provider Name (Legal Business Name): HANNAH RENEE BULLOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 NEWCOMB AVE
MOUNT VERNON KY
40456-2725
US

IV. Provider business mailing address

140 NEWCOMB AVE
MOUNT VERNON KY
40456-2725
US

V. Phone/Fax

Practice location:
  • Phone: 606-256-4148
  • Fax: 606-256-7785
Mailing address:
  • Phone: 606-256-4148
  • Fax: 606-256-7785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number59179
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: