Provider Demographics
NPI:1568604197
Name:BULLOCK, LESLI
Entity Type:Individual
Prefix:
First Name:LESLI
Middle Name:
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 1:14100 PARKWAY COMMONS DR STE 201
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-6104
Mailing Address - Country:US
Mailing Address - Phone:405-749-2765
Mailing Address - Fax:405-749-6209
Practice Address - Street 1:14100 PARKWAY COMMONS DR STE 201
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6104
Practice Address - Country:US
Practice Address - Phone:405-749-2765
Practice Address - Fax:405-749-6209
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK119449363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1568604197Medicaid
AL112840Medicaid