Provider Demographics
NPI:1316183023
Name:BULLOCK, LORRAINE (NP)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22402-1460
Mailing Address - Country:US
Mailing Address - Phone:540-785-2100
Mailing Address - Fax:
Practice Address - Street 1:300 PARK HILL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3387
Practice Address - Country:US
Practice Address - Phone:540-361-7641
Practice Address - Fax:540-361-1246
Is Sole Proprietor?:No
Enumeration Date:2008-12-30
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316183023OtherVA PREMIER
VA1316183023Medicaid
VA1316183023Medicaid