Basic Information
| Provider Information | |||||||||
| NPI: | 1588257463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLARD | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAPP | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | WOMACK ARMY MEDICAL CENTER | ||||||||
| Address2: | 2817 REILLY ROAD | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078617 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | WAMC / MEDCOM | ||||||||
| Address2: | 2817 REILLY ROAD | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078617 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2021 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0400X | 138163 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Case Management |
No ID Information.