Provider Demographics
NPI:1174802565
Name:BULLOCK, STACIE MAREE (CRNP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:MAREE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5603
Mailing Address - Country:US
Mailing Address - Phone:205-930-0920
Mailing Address - Fax:
Practice Address - Street 1:3485 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-5603
Practice Address - Country:US
Practice Address - Phone:205-930-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-110629363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner