1346752151 NPI number — MS. CHANEL DOMINQUE BULLOCK APN, FNP-C

Table of content: MS. CHANEL DOMINQUE BULLOCK APN, FNP-C (NPI 1346752151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346752151 NPI number — MS. CHANEL DOMINQUE BULLOCK APN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BULLOCK
Provider First Name:
CHANEL
Provider Middle Name:
DOMINQUE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APN, FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346752151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 N SHACKLEFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72211-2840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-215-0731
Provider Business Mailing Address Fax Number:
888-630-8885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2711 W KINGSHIGHWAY STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARAGOULD
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72450-2645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-522-1275
Provider Business Practice Location Address Fax Number:
833-888-7145
Provider Enumeration Date:
11/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  A005316 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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