Basic Information
| Provider Information | |||||||||
| NPI: | 1316183023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | LORRAINE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1460 | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224021460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407852100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 PARK HILL DR | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224013387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403617641 | ||||||||
| FaxNumber: | 5403611246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 10/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024168125 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1316183023 | 01 | VA | VA PREMIER | OTHER | 1316183023 | 05 | VA | MEDICAID |