Provider Demographics
NPI:1922166685
Name:BULLY, TARA MICHELLE (FNP, APNP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MICHELLE
Last Name:BULLY
Suffix:
Gender:F
Credentials:FNP, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:7878 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-3914
Practice Address - Country:US
Practice Address - Phone:414-354-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2477-033363LF0000X
WI2477363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI002760041Medicare ID - Type Unspecified
WIQ67851Medicare UPIN
WI002768237Medicare ID - Type Unspecified
WI002701418Medicare ID - Type Unspecified