Provider Demographics
NPI:1841802634
Name:BULLOCK, SHAUNE (FNP)
Entity Type:Individual
Prefix:
First Name:SHAUNE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 954
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-0954
Mailing Address - Country:US
Mailing Address - Phone:720-979-1617
Mailing Address - Fax:
Practice Address - Street 1:8899 S 700 E STE 250
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-1813
Practice Address - Country:US
Practice Address - Phone:801-996-4306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT201825-8900363LF0000X
UT201825-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily