Provider Demographics
NPI:1447727912
Name:BULL, LESSLIE R (CNM)
Entity type:Individual
Prefix:
First Name:LESSLIE
Middle Name:R
Last Name:BULL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:177-408-4008
Mailing Address - Fax:
Practice Address - Street 1:150 RIVER NORTH BLVD
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-1860
Practice Address - Country:US
Practice Address - Phone:254-968-6051
Practice Address - Fax:254-968-1860
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139212367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife