Provider Demographics
NPI:1205841624
Name:SHARON M BULLOCK
Entity Type:Organization
Organization Name:SHARON M BULLOCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT LPN
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:M
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:513-709-9344
Mailing Address - Street 1:4549 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5607
Mailing Address - Country:US
Mailing Address - Phone:513-398-2456
Mailing Address - Fax:
Practice Address - Street 1:4549 COOPER RD
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-5607
Practice Address - Country:US
Practice Address - Phone:513-398-2456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN090343164W00000X, 251E00000X, 302F00000X, 302R00000X, 305R00000X
OHBRODI343900000X
OHRP227337347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Not Answered251E00000XAgenciesHome Health
Not Answered302F00000XManaged Care OrganizationsExclusive Provider Organization
Not Answered302R00000XManaged Care OrganizationsHealth Maintenance Organization
Not Answered305R00000XManaged Care OrganizationsPreferred Provider Organization
Not Answered343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Not Answered347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherSOCIAL SECURITY NUMBER