MEDICARE: MRS. AVE' MARIA BULLARD P. T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	2305003048	VA

General Provider Information

NPI Number	:	1598105199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AVE' MARIA BULLARD P. T.

Provider Business Mailing Address
First Line	:	5998 PROVIDENCE RD
Second Line	:	SUITE 106
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-3824
Country	:	US
Telephone Number	:	757-672-6490
Fax Number	:

Provider Business Practice Location Address
First Line	:	5998 PROVIDENCE RD
Second Line	:	SUITE 106
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-3824
Country	:	US
Telephone Number	:	757-672-6490
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2013
Last Update Date	:	06/27/2013

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