Healthcare Provider Details

I. General information

NPI: 1124175526
Provider Name (Legal Business Name): JOSEPHINE L BULLOCK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST C1831
DETROIT MI
48201-1916
US

IV. Provider business mailing address

4646 JOHN R ST C1831
DETROIT MI
48201-1916
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-4431
  • Fax: 313-576-1812
Mailing address:
  • Phone: 313-576-4431
  • Fax: 313-576-1812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704095091
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: