Healthcare Provider Details

I. General information

NPI: 1679819841
Provider Name (Legal Business Name): SANDRA JEAN BULLOCK R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 COLLINGWOOD BLVD
LIMA OH
45801-1811
US

IV. Provider business mailing address

400 COLLINGWOOD BLVD
LIMA OH
45801-1811
US

V. Phone/Fax

Practice location:
  • Phone: 419-303-9408
  • Fax:
Mailing address:
  • Phone: 419-303-9408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN364784
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN364784
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License NumberRN364784
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberRN364784
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: