Basic Information
| Provider Information | |||||||||
| NPI: | 1497071658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | TESHAMA | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROCK | ||||||||
| OtherFirstName: | TESHAMA | ||||||||
| OtherMiddleName: | NICHOLE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.N. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7445 SW 168TH ST | ||||||||
| Address2: | |||||||||
| City: | PALMETTO BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331574814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214127129 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6200 SW 73RD ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331434679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866624000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 04/13/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 200942602RN | OR | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN 9291520 | FL | Y | Nursing Service Providers | Registered Nurse |
No ID Information.