Provider Demographics
NPI:1770939084
Name:BULLOCK, LINSEY (ARNP)
Entity type:Individual
Prefix:
First Name:LINSEY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LINSEY
Other - Middle Name:
Other - Last Name:BRANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4665 S STATE ROAD 5
Practice Address - Street 2:
Practice Address - City:SOUTH WHITLEY
Practice Address - State:IN
Practice Address - Zip Code:46787-9101
Practice Address - Country:US
Practice Address - Phone:260-248-9980
Practice Address - Fax:260-248-9981
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60635392363LF0000X
IN71015472A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily