Individual
MARY G BULLOCK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
RN, CNP
Contact information
Practice address
2845 HAMLINE AVE NORTH, ROSEVILLE, MN 55113
(651) 631-6100
(651) 631-6343
Mailing address
2845 HAMLINE AVE NORTH, ROSEVILLE, MN 55113
(651) 631-6100
(651) 631-6343
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
R119074-4
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6676570-0
—
MN
Enumeration date
09/16/2006
Last updated
04/25/2012
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