Basic Information
| Provider Information | |||||||||
| NPI: | 1083981757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULLIE | ||||||||
| FirstName: | BIANCA | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E WOODROW WILSON | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013684089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E WOODROW WILSON | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013684089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2011 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN867841 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN867841 | 01 | MS | MS BOARD OF NURSING LICENSE NUMBER | OTHER |