Healthcare Provider Details

I. General information

NPI: 1205841624
Provider Name (Legal Business Name): SHARON M BULLOCK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4549 COOPER RD
BLUE ASH OH
45242-5607
US

IV. Provider business mailing address

4549 COOPER RD
BLUE ASH OH
45242-5607
US

V. Phone/Fax

Practice location:
  • Phone: 513-398-2456
  • Fax:
Mailing address:
  • Phone: 513-398-2456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberPN090343
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberPN090343
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberPN090343
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberPN090343
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberBRODI
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberRP227337
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN090343
License Number StateOH

VIII. Authorized Official

Name: MRS. SHARON M BULLOCK
Title or Position: INDEPENDENT LPN
Credential: LPN
Phone: 513-709-9344