Provider Demographics
NPI:1003465402
Name:BULLOCK, MONIESHA AVITA JAVON
Entity Type:Individual
Prefix:
First Name:MONIESHA
Middle Name:AVITA JAVON
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 1:508 LITTLE MARGARET LN
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23075-1647
Mailing Address - Country:US
Mailing Address - Phone:804-822-8661
Mailing Address - Fax:
Practice Address - Street 1:508 LITTLE MARGARET LN
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23075-1647
Practice Address - Country:US
Practice Address - Phone:804-822-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care