Provider Demographics
NPI:1003523846
Name:BULABULA, GAELLE MAVILUKA
Entity Type:Individual
Prefix:
First Name:GAELLE
Middle Name:MAVILUKA
Last Name:BULABULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 ELM HILL PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214-3108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1217 S RANGELINE RD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2519
Practice Address - Country:US
Practice Address - Phone:317-846-4818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71013415A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily