Healthcare Provider Details

I. General information

NPI: 1649189473
Provider Name (Legal Business Name): CLINTON BROCKA BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10580 N MERIDIAN ST
CARMEL IN
46290-1028
US

IV. Provider business mailing address

8515 CLEARWATER LN APT 204
INDIANAPOLIS IN
46240-1580
US

V. Phone/Fax

Practice location:
  • Phone: 317-583-5000
  • Fax:
Mailing address:
  • Phone: 773-849-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28280386A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: