Healthcare Provider Details

I. General information

NPI: 1346815172
Provider Name (Legal Business Name): BREANNA MARIE BROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNA MARIE HALL

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36TH MEDICAL GROUP UNIT 14010 BLDG. 26012
APO AP
96543
UM

IV. Provider business mailing address

CHESTER STREET, LAKENHEATH
BRANDON SUFFOLK
IP27 9PS
GB

V. Phone/Fax

Practice location:
  • Phone: 671-366-2419
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: