Provider Demographics
NPI:1104822360
Name:BULLOCK, TODD E (APRN)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:E
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1479
Mailing Address - Country:US
Mailing Address - Phone:270-259-1626
Mailing Address - Fax:270-259-9582
Practice Address - Street 1:301 SUNSET DR
Practice Address - Street 2:
Practice Address - City:CANEYVILLE
Practice Address - State:KY
Practice Address - Zip Code:42721-9172
Practice Address - Country:US
Practice Address - Phone:270-879-3711
Practice Address - Fax:270-879-8674
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004076363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000302145OtherANTHEM
KY2443164000OtherPASSPORT ADVANTAGE
KY50001589OtherPASSPORT
KY78010436Medicaid
P95440Medicare UPIN
KY50001589OtherPASSPORT