Provider Demographics
NPI:1679819841
Name:BULLOCK, SANDRA JEAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JEAN
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 1:400 COLLINGWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-1811
Mailing Address - Country:US
Mailing Address - Phone:419-303-9408
Mailing Address - Fax:
Practice Address - Street 1:400 COLLINGWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-1811
Practice Address - Country:US
Practice Address - Phone:419-303-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN364784163WC0400X, 163WH0200X, 163WH1000X, 163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy