Healthcare Provider Details

I. General information

NPI: 1639627110
Provider Name (Legal Business Name): MARY KAY BULTMAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 N 12TH ST FL 4
MILWAUKEE WI
53233-1308
US

IV. Provider business mailing address

1020 N 12TH ST FL 4
MILWAUKEE WI
53233-1308
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-2000
  • Fax: 414-219-7402
Mailing address:
  • Phone: 414-219-2000
  • Fax: 414-219-7402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number60996-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7252-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: