Provider Demographics
NPI:1417286535
Name:BULLOCK, DIANE O (LPN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:O
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LPN
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 17523
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-0523
Mailing Address - Country:US
Mailing Address - Phone:585-490-3369
Mailing Address - Fax:
Practice Address - Street 1:2660 CHILI AVE
Practice Address - Street 2:BLDG 28 APT 14
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-4101
Practice Address - Country:US
Practice Address - Phone:585-490-3369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-19
Last Update Date:2009-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210139-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse