Provider Demographics
NPI:1891878641
Name:BULLOCK, TRACIE L (APRN)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:L
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 CENTERPOINT BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1984
Mailing Address - Country:US
Mailing Address - Phone:865-985-7494
Mailing Address - Fax:
Practice Address - Street 1:1431 CENTERPOINT BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-1984
Practice Address - Country:US
Practice Address - Phone:865-985-7494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003142363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78004785Medicaid
KY000000646027OtherBCBS
KY78004785Medicaid
KY000000646027OtherBCBS