Provider Demographics
NPI:1124815592
Name:BULLARD, OLIVIA NAOMIE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NAOMIE
Last Name:BULLARD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 COMMERCE PLAZA CIR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-7386
Mailing Address - Country:US
Mailing Address - Phone:910-521-2900
Mailing Address - Fax:
Practice Address - Street 1:210 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1956
Practice Address - Country:US
Practice Address - Phone:910-628-6711
Practice Address - Fax:910-628-5735
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-15150363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant