Provider Demographics
NPI:1669620506
Name:BULLOCK, BOBBI ANNETTE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:BOBBI
Middle Name:ANNETTE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:BOBBI
Other - Middle Name:ANNETTE
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1611 12TH AVE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-7715
Mailing Address - Country:US
Mailing Address - Phone:208-468-9400
Mailing Address - Fax:
Practice Address - Street 1:1611 12TH AVE RD
Practice Address - Street 2:SUITE A
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-7715
Practice Address - Country:US
Practice Address - Phone:208-468-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-879A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily