Provider Demographics
NPI:1417337262
Name:BULLOCK, DARCI (LPN)
Entity Type:Individual
Prefix:
First Name:DARCI
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-3817
Mailing Address - Country:US
Mailing Address - Phone:269-845-0032
Mailing Address - Fax:
Practice Address - Street 1:1638 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3817
Practice Address - Country:US
Practice Address - Phone:269-845-0032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703099274164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse