Provider Demographics
NPI:1033144340
Name:BULK, KELLY JEAN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:BULK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11 N MAPLE ST
Mailing Address - Street 2:PO BOX 7
Mailing Address - City:GRANT
Mailing Address - State:MI
Mailing Address - Zip Code:49327-7900
Mailing Address - Country:US
Mailing Address - Phone:231-834-0444
Mailing Address - Fax:231-834-0200
Practice Address - Street 1:11 N MAPLE
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:MI
Practice Address - Zip Code:49327
Practice Address - Country:US
Practice Address - Phone:231-834-0444
Practice Address - Fax:231-834-0200
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q03408Medicare UPIN
N81620001Medicare ID - Type Unspecified