1952641680 NPI number — BROOKE KERN BROCK APRN

Table of content: BROOKE KERN BROCK APRN (NPI 1952641680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952641680 NPI number — BROOKE KERN BROCK APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK
Provider First Name:
BROOKE
Provider Middle Name:
KERN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KERN
Provider Other First Name:
BROOKE
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1952641680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 W HILLSBORO BLVD STE 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COCONUT CREEK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33073-4397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-570-7644
Provider Business Mailing Address Fax Number:
954-570-7884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 W HILLSBORO BLVD
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
COCONUT CREEK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33073-4395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-570-7644
Provider Business Practice Location Address Fax Number:
954-570-7884
Provider Enumeration Date:
02/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  ARNP 9295455 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100399800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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