Provider Demographics
NPI:1508294315
Name:BULLARD, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BULLARD
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 1:3724 JEFFERSON ST STE 104
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6204
Mailing Address - Country:US
Mailing Address - Phone:512-692-7045
Mailing Address - Fax:
Practice Address - Street 1:116 VALLEY VIEW DR N
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-3209
Practice Address - Country:US
Practice Address - Phone:817-528-8617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-15
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT03609133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered