Provider Demographics
NPI:1649983198
Name:BULLOCK, BRENT JAMES (PMHNP, APRN)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:JAMES
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PMHNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1688 N 210 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2203
Mailing Address - Country:US
Mailing Address - Phone:385-233-7689
Mailing Address - Fax:
Practice Address - Street 1:1125 W CENTER ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-5207
Practice Address - Country:US
Practice Address - Phone:801-903-5903
Practice Address - Fax:801-515-0935
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8695221-3102163W00000X
UT8695221-4405363LP0808X
UT8695221-8900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse