Provider Demographics
NPI:1710295654
Name:BULLOCK, JOEANN (LPN)
Entity Type:Individual
Prefix:MS
First Name:JOEANN
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:JOEANN
Other - Middle Name:
Other - Last Name:MAYBEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:297 8TH ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2301
Mailing Address - Country:US
Mailing Address - Phone:518-227-8847
Mailing Address - Fax:
Practice Address - Street 1:297 8TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2301
Practice Address - Country:US
Practice Address - Phone:518-227-8847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138565-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse