Healthcare Provider Details

I. General information

NPI: 1407941057
Provider Name (Legal Business Name): KELLY LEIGH BULLOCK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E WAYNE ST
RANDOLPH NE
68771-5300
US

IV. Provider business mailing address

1415 CHAROLAIS DRIVE
NORFOLK NE
68701
US

V. Phone/Fax

Practice location:
  • Phone: 402-337-0200
  • Fax: 402-337-1020
Mailing address:
  • Phone: 402-379-1997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number461
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: