Provider Demographics
NPI:1205932902
Name:BULLOCK, MARY G (RN, CNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 HAMLINE AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-631-6100
Mailing Address - Fax:651-631-6343
Practice Address - Street 1:2845 HAMLINE AVE NORTH
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-631-6100
Practice Address - Fax:651-631-6343
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR119074-4363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6676570-0Medicaid
MNP70940Medicare UPIN
MN6676570-0Medicaid