Healthcare Provider Details

I. General information

NPI: 1396191888
Provider Name (Legal Business Name): NIDIA BULLARD CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FULTON AVE STE 100
HEMPSTEAD NY
11550-3702
US

IV. Provider business mailing address

222 STATION PLZ N STE 611
MINEOLA NY
11501-3893
US

V. Phone/Fax

Practice location:
  • Phone: 516-292-1034
  • Fax: 516-292-0565
Mailing address:
  • Phone: 516-292-1034
  • Fax: 516-292-0565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF382580
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: