Provider Demographics
NPI:1609677707
Name:BULLOCK, SHELLY LAREE
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:LAREE
Last Name:BULLOCK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-3545
Mailing Address - Country:US
Mailing Address - Phone:979-245-5721
Mailing Address - Fax:979-245-1482
Practice Address - Street 1:1120 AVENUE G
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-3541
Practice Address - Country:US
Practice Address - Phone:979-245-5721
Practice Address - Fax:979-245-1482
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1193041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily