=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033070412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AQILAH RIVENS BULLEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2025
-----------------------------------------------------
Last Update Date | 11/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5840 E WT HARRIS BLVD STE 109 PMB 1074
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-739-6249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5840 E WT HARRIS BLVD STE 109 PMB 1074
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-739-6249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 22791
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------