Provider Demographics
NPI:1598300121
Name:BULLOCK, SARA E (RN)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:E
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 PERRYSBURG HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9582
Mailing Address - Country:US
Mailing Address - Phone:419-693-1520
Mailing Address - Fax:419-693-3295
Practice Address - Street 1:U469 COUNTY ROAD 1D
Practice Address - Street 2:
Practice Address - City:LIBERTY CENTER
Practice Address - State:OH
Practice Address - Zip Code:43532-9598
Practice Address - Country:US
Practice Address - Phone:419-693-1520
Practice Address - Fax:419-693-3295
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.410454163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse