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General NPI Number Information
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NPI Number | 1346752151
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Entity Type | Individual
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Provider Name | CHANEL DOMINQUE BULLOCK APN, FNP-C
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Gender | Female
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Dates
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Enumeration Date | 11/02/2017
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 2711 W KINGSHIGHWAY STE 10
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City | PARAGOULD
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State | AR
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Zip | 72450-2645
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Country | US
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Telephone | 877-522-1275
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Fax | 833-888-7145
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Provider Business Mailing Address
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Address Line | 108 N SHACKLEFORD RD
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City | LITTLE ROCK
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State | AR
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Zip | 72211-2840
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Country | US
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Telephone | 844-215-0731
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Fax | 888-630-8885
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | A005316
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License Number State | AR
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