Provider Demographics
NPI:1477293850
Name:BULL, STEPHANIE CHARLENE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CHARLENE
Last Name:BULL
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 1:205 MAIN CIR
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4991
Mailing Address - Country:US
Mailing Address - Phone:801-668-8043
Mailing Address - Fax:
Practice Address - Street 1:333 LAWS AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-6540
Practice Address - Country:US
Practice Address - Phone:707-468-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA65003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program