Provider Demographics
NPI:1205483682
Name:O'CONNELL, ELYSE BULLOCK (FNP)
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:BULLOCK
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ELYSE
Other - Middle Name:KATHERINE ROSE
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:796 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4571
Mailing Address - Country:US
Mailing Address - Phone:336-598-0002
Mailing Address - Fax:
Practice Address - Street 1:796 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4571
Practice Address - Country:US
Practice Address - Phone:336-598-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC265665207Q00000X
NCBULL-K27AKJ207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine