Provider Demographics
NPI:1487353769
Name:BROCKINGTON, ETHEL M
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:M
Last Name:BROCKINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1755
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33568-1755
Mailing Address - Country:US
Mailing Address - Phone:813-426-6730
Mailing Address - Fax:
Practice Address - Street 1:13027 TRIBUTE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7574
Practice Address - Country:US
Practice Address - Phone:813-426-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide