Provider Demographics
NPI:1902043920
Name:BULLOCK, KATIE (RD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:18TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 5142
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96368
Mailing Address - Country:US
Mailing Address - Phone:571-364-9277
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368-5142
Practice Address - Country:US
Practice Address - Phone:571-364-9277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
999172133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered