Mary Kay Bultman, PMHNP

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

60996-30 Issued in WI

Practice address

1020 N 12TH St FL 4
Milwaukee, WI 53233-1308

Phone

(414) 219-2000

Fax

(414) 219-7402

NPI assigned

Sep 14, 2016

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in WI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2016

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Lighthouse Clinic LLCGroup PAC ID 4385826502, 14 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Lighthouse Clinic

  • Psychologist
  • Milwaukee, WI
  • NPI 1912216219

  WI

  Medicare reassignment Care Compare group NPD
• Aurora Medical Group, Inc.

  • Durable Medical Equipment & Medical Supplies
  • Manitowoc, WI
  • NPI 1801941075
  NPD (past)
• Aurora Sinai Medical Center, Inc.

  • Rehabilitation Hospital Unit
  • Milwaukee, WI
  • NPI 1265605166
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1473811200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1583452800000",
    "number": "1639627110",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1020 N 12TH ST FL 4",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532331308",
            "telephone_number": "414-219-2000",
            "fax_number": "414-219-7402"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1020 N 12TH ST FL 4",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532331308",
            "telephone_number": "414-219-2000",
            "fax_number": "414-219-7402"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BULTMAN",
        "first_name": "MARY KAY",
        "credential": "PMHNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-09-14",
        "last_updated": "2020-03-06",
        "certification_date": "2020-03-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "WI",
            "license": "60996-30",
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "WI",
            "license": "7252",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100062610",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100080285",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Lisa Marie Bullis, MSN, APNP
• Allison Marie Bullock
• Tara W Bulluck-McSwain, RN
• Tara Michelle Bully, FNP, APNP
• Emily Bulthuis
• Rochelle Ann Bumbalek, RN, MPAS
• Bump & Beyond LLC
• Bump to Bliss Prenatal LLC
• Bump to Bundle LLC
• Bundle of Love Prenatal LLC

• All providers in Milwaukee, WI
• Psychiatric/Mental Health Nurse Practitioner in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 6, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.