Provider Demographics
NPI:1710382577
Name:BULLOCK, SHARON
Entity Type:Individual
Prefix:
First Name:SHARON
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 1:850 S ORANGE AVE
Mailing Address - Street 2:PO 6188
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-1941
Mailing Address - Country:US
Mailing Address - Phone:973-399-7630
Mailing Address - Fax:
Practice Address - Street 1:850 S ORANGE AVE
Practice Address - Street 2:PO 6188
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-1941
Practice Address - Country:US
Practice Address - Phone:973-399-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker