Provider Demographics
NPI:1134398209
Name:BULLEN, ALTHEA LAVERNIE (RN)
Entity type:Individual
Prefix:MISS
First Name:ALTHEA
Middle Name:LAVERNIE
Last Name:BULLEN
Suffix:
Gender:
Credentials:RN
Other - Prefix:MISS
Other - First Name:ALTHEA
Other - Middle Name:LAVERNIE
Other - Last Name:BULLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1557 FIFTH AVE APT 252
Mailing Address - Street 2:
Mailing Address - City:BAYSHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-3441
Mailing Address - Country:US
Mailing Address - Phone:631-582-3409
Mailing Address - Fax:
Practice Address - Street 1:1557 FIFTH AVE APT 252
Practice Address - Street 2:
Practice Address - City:BAYSHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-3441
Practice Address - Country:US
Practice Address - Phone:631-582-3409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328093163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01242497Medicaid