Provider Demographics
NPI:1134555139
Name:BULLOCK, MARLISA (NP)
Entity type:Individual
Prefix:
First Name:MARLISA
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARLISA
Other - Middle Name:
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:269 GILLMAN RD STE 100
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-7923
Practice Address - Country:US
Practice Address - Phone:704-316-4930
Practice Address - Fax:704-316-4931
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222885363LA2200X
NC5011333363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health