Provider Demographics
NPI:1811761711
Name:BULCHAK, MALLORY KAY (NP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:KAY
Last Name:BULCHAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29216 BONNIE DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3567
Mailing Address - Country:US
Mailing Address - Phone:248-829-0456
Mailing Address - Fax:
Practice Address - Street 1:29216 BONNIE DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3567
Practice Address - Country:US
Practice Address - Phone:248-829-0456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704352280163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health