Healthcare Provider Details

I. General information

NPI: 1790429140
Provider Name (Legal Business Name): ASHLEY MICHELLE BULLOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY DEVILLE

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4541
  • Fax: 225-765-9196
Mailing address:
  • Phone: 318-966-4541
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number346459
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number346459
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: