Provider Demographics
NPI:1083321301
Name:BULLOCK, AFFIE ANN
Entity type:Individual
Prefix:
First Name:AFFIE
Middle Name:ANN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26797 ROSELAND RD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-6122
Mailing Address - Country:US
Mailing Address - Phone:574-215-6628
Mailing Address - Fax:
Practice Address - Street 1:26797 ROSELAND RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-6122
Practice Address - Country:US
Practice Address - Phone:574-215-6628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN597RBZ347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle