Provider Demographics
NPI:1518190180
Name:BULLOCK, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-1960
Mailing Address - Country:US
Mailing Address - Phone:320-589-7425
Mailing Address - Fax:320-589-7433
Practice Address - Street 1:621 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1960
Practice Address - Country:US
Practice Address - Phone:320-589-7425
Practice Address - Fax:320-589-7433
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR149320-5163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator