Provider Demographics
NPI:1659751865
Name:BULLOCK, MAGGIE (NP-C)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1726
Mailing Address - Country:US
Mailing Address - Phone:931-783-5582
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:340 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2421
Practice Address - Country:US
Practice Address - Phone:931-783-5353
Practice Address - Fax:931-783-4994
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNF0615007363LF0000X
TN20367363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6073121OtherBCBS - TIN: 626002166
TN6075769OtherBCBS - TIN: 200992504
TN7100424650Medicaid
TNQ022139Medicaid
TN103503I399Medicare PIN