Provider Demographics
NPI:1922429554
Name:BULTMAN, DAWN
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:
Last Name:BULTMAN
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 1:6630 GRAN VIA CT NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9692
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6630 GRAN VIA CT NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9692
Practice Address - Country:US
Practice Address - Phone:616-240-3023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-28
Last Update Date:2013-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704214966163W00000X, 163WG0000X, 163WH0200X, 163WM0102X, 163WN0003X, 163WP0807X, 163WP0808X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult