Basic Information
Provider Information | |||||||||
NPI: | 1063523413 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROCKLEY | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6090 REDWOOD BLVD G | ||||||||
Address2: |   | ||||||||
City: | NOVATO | ||||||||
State: | CA | ||||||||
PostalCode: | 949454569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4157983106 | ||||||||
FaxNumber: | 4157983180 | ||||||||
Practice Location | |||||||||
Address1: | 361 3RD ST STE E | ||||||||
Address2: |   | ||||||||
City: | SAN RAFAEL | ||||||||
State: | CA | ||||||||
PostalCode: | 94901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4154994030 | ||||||||
FaxNumber: | 4155072634 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 09/28/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WW0101X | 368074 | CA | N |   | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory | 363LW0102X | 8387 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.