Provider Demographics
NPI:1285168344
Name:BULLOCK, REBEKAH KATE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:KATE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 RIVER BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35811-9757
Mailing Address - Country:US
Mailing Address - Phone:816-383-3766
Mailing Address - Fax:
Practice Address - Street 1:4040 MEMORIAL PKWY SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-4364
Practice Address - Country:US
Practice Address - Phone:256-533-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-16
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-172431363LP0808X, 363LP0808X
MO2017002875363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000014Medicaid