Provider Demographics
NPI:1104491414
Name:BULTMAN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BULTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 COMMONS BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3821
Mailing Address - Country:US
Mailing Address - Phone:513-833-4912
Mailing Address - Fax:
Practice Address - Street 1:2510 COMMONS BLVD STE 210
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3821
Practice Address - Country:US
Practice Address - Phone:513-833-4912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006573RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant