Healthcare Provider Details

I. General information

NPI: 1346752151
Provider Name (Legal Business Name): CHANEL DOMINQUE BULLOCK APN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 W KINGSHIGHWAY STE 10
PARAGOULD AR
72450-2645
US

IV. Provider business mailing address

108 N SHACKLEFORD RD
LITTLE ROCK AR
72211-2840
US

V. Phone/Fax

Practice location:
  • Phone: 877-522-1275
  • Fax: 833-888-7145
Mailing address:
  • Phone: 844-215-0731
  • Fax: 888-630-8885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA005316
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: