Provider Demographics
NPI:1871049510
Name:BULLOCK, STEPHANIE MARIE (SA)
Entity type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:SA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SA
Mailing Address - Street 1:833 CAMPBELL HILL ST NW STE 280
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:770-485-7628
Mailing Address - Fax:678-403-1081
Practice Address - Street 1:833 CAMPBELL HILL ST NW STE 280
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-485-7628
Practice Address - Fax:678-403-1081
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant