Provider Demographics
NPI:1992082614
Name:BROCK, SHIRLEY (LPN)
Entity type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 COUNTY ROUTE ROAD 22
Mailing Address - Street 2:
Mailing Address - City:PARISH
Mailing Address - State:NY
Mailing Address - Zip Code:13131
Mailing Address - Country:US
Mailing Address - Phone:315-625-7375
Mailing Address - Fax:
Practice Address - Street 1:565 COUNTY ROUTE 22
Practice Address - Street 2:
Practice Address - City:PARISH
Practice Address - State:NY
Practice Address - Zip Code:13131-3181
Practice Address - Country:US
Practice Address - Phone:315-625-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289124-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse