Provider Demographics
NPI:1124275045
Name:BULLANDAY, LORIDA ESTOMO (PT)
Entity type:Individual
Prefix:
First Name:LORIDA
Middle Name:ESTOMO
Last Name:BULLANDAY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SE ASTER LN
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-5516
Mailing Address - Country:US
Mailing Address - Phone:772-324-7558
Mailing Address - Fax:
Practice Address - Street 1:3400 SE ASTER LN
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-5516
Practice Address - Country:US
Practice Address - Phone:772-324-7558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18395225100000X
FL28284225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist