=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649189473
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLINTON BROCKA BSN, RN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2026
-----------------------------------------------------
Last Update Date | 09/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10580 N MERIDIAN ST
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46290-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-583-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8515 CLEARWATER LN APT 204
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46240-1580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-849-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 28280386A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------