Healthcare Provider Details

I. General information

NPI: 1205767019
Provider Name (Legal Business Name): DOMINIQUE BULLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 Q ST NE APT 2114
WASHINGTON DC
20002-2386
US

IV. Provider business mailing address

3319 WALTERS LN APT 101
DISTRICT HEIGHTS MD
20747-5121
US

V. Phone/Fax

Practice location:
  • Phone: 202-449-0783
  • Fax:
Mailing address:
  • Phone: 202-907-9302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: