Healthcare Provider Details

I. General information

NPI: 1689090466
Provider Name (Legal Business Name): BREANNA BROCK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2014
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 HATHERLY DR
HAMILTON OH
45013-2016
US

IV. Provider business mailing address

183 HATHERLY DR
HAMILTON OH
45013-2016
US

V. Phone/Fax

Practice location:
  • Phone: 513-330-1454
  • Fax:
Mailing address:
  • Phone: 513-330-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number394589
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: