Provider Demographics
NPI:1376187922
Name:BULLOCH, MACKENZIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BULLOCH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 BELMONT AVE APT 4116
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6880
Mailing Address - Country:US
Mailing Address - Phone:214-415-5974
Mailing Address - Fax:
Practice Address - Street 1:9101 N CENTRAL EXPY STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5956
Practice Address - Country:US
Practice Address - Phone:214-660-5754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143194363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily