MEDICARE: AMANDA BULLOCK RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WS0200X	School Registered Nurse	258475-30	WI

General Provider Information

NPI Number	:	1669300125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA BULLOCK RN

Provider Business Mailing Address
First Line	:	611 TWO MILE AVE
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54494-6560
Country	:	US
Telephone Number	:	715-424-6793
Fax Number	:	715-424-6794

Provider Business Practice Location Address
First Line	:	611 TWO MILE AVE
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54494-6560
Country	:	US
Telephone Number	:	715-424-6793
Fax Number	:	715-424-6794

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2026
Last Update Date	:	05/13/2026

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