MEDICARE: MISS STEPHANIE MARIE BULLOCK CSA

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	246ZC0007X	Surgical Assistant

General Provider Information

NPI Number	:	1871049510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS STEPHANIE MARIE BULLOCK CSA

Provider Business Mailing Address
First Line	:	277 COVINGTON DR
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-2257
Country	:	US
Telephone Number	:	757-287-8914
Fax Number	:	844-550-4221

Provider Business Practice Location Address
First Line	:	277 COVINGTON DR
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-2257
Country	:	US
Telephone Number	:	757-287-8914
Fax Number	:	844-550-4221

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

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	12/18/2025

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