Healthcare Provider Details

I. General information

NPI: 1063523413
Provider Name (Legal Business Name): PATRICIA MARY BROCKLEY NP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 3RD ST STE E
SAN RAFAEL CA
94901
US

IV. Provider business mailing address

6090 REDWOOD BLVD G
NOVATO CA
94945-4569
US

V. Phone/Fax

Practice location:
  • Phone: 415-499-4030
  • Fax: 415-507-2634
Mailing address:
  • Phone: 415-798-3106
  • Fax: 415-798-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number368074
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number8387
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: