Healthcare Provider Details

I. General information

NPI: 1134555139
Provider Name (Legal Business Name): MARLISA BULLOCK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARLISA BULLOCK NP

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 10/26/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 GILLMAN RD STE 100
DENVER NC
28037-7923
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-4930
  • Fax: 704-316-4931
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704222885
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5011333
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: