Provider Demographics
NPI:1255527412
Name:BULLOCK-SANDERS, MELONIE (N/A)
Entity type:Individual
Prefix:MS
First Name:MELONIE
Middle Name:
Last Name:BULLOCK-SANDERS
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4818
Mailing Address - Country:US
Mailing Address - Phone:940-577-8536
Mailing Address - Fax:972-753-6400
Practice Address - Street 1:1915 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4818
Practice Address - Country:US
Practice Address - Phone:940-577-8536
Practice Address - Fax:972-753-6400
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012794099171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty