Basic Information
Provider Information | |||||||||
NPI: | 1659751865 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BULLOCK | ||||||||
FirstName: | MAGGIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 140 W 7TH ST | ||||||||
Address2: |   | ||||||||
City: | COOKEVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 385011726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9317835582 | ||||||||
FaxNumber: | 9315266760 | ||||||||
Practice Location | |||||||||
Address1: | 340 N CEDAR AVE | ||||||||
Address2: |   | ||||||||
City: | COOKEVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 385012421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9317835353 | ||||||||
FaxNumber: | 9317834994 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2015 | ||||||||
LastUpdateDate: | 05/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F0615007 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 6075769 | 01 | TN | BCBS - TIN: 200992504 | OTHER | Q022139 | 05 | TN |   | MEDICAID | 7100424650 | 05 | TN |   | MEDICAID | 6073121 | 01 | TN | BCBS - TIN: 626002166 | OTHER |