Basic Information
| Provider Information | |||||||||
| NPI: | 1134555139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | MARLISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BULLOCK | ||||||||
| OtherFirstName: | MARLISA | ||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 269 GILLMAN RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280377923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043164930 | ||||||||
| FaxNumber: | 7043164931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 4704222885 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 5011333 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.