Provider Demographics
NPI:1346752151
Name:BULLOCK, CHANEL DOMINQUE (APN, FNP-C)
Entity Type:Individual
Prefix:MS
First Name:CHANEL
Middle Name:DOMINQUE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:APN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N SHACKLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2840
Mailing Address - Country:US
Mailing Address - Phone:844-215-0731
Mailing Address - Fax:888-630-8885
Practice Address - Street 1:108 N SHACKLEFORD RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2840
Practice Address - Country:US
Practice Address - Phone:844-215-0731
Practice Address - Fax:888-630-8885
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily