Provider Demographics
NPI:1700658564
Name:BULLOCK, LISA JEAN
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JEAN
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 1:14727 BADEN RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45327-9407
Mailing Address - Country:US
Mailing Address - Phone:937-604-1811
Mailing Address - Fax:
Practice Address - Street 1:14727 BADEN RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:OH
Practice Address - Zip Code:45327-9407
Practice Address - Country:US
Practice Address - Phone:937-604-1811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker