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General NPI Number Information
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NPI Number | 1871108233
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Entity Type | Individual
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Provider Name | RICKY BROCKINGTON
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Gender | Male
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Dates
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Enumeration Date | 09/12/2020
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Last Update Date | 08/12/2021
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Provider Practice Location Address
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Address Line | 102 FAIRVIEW DR STE B
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City | FRANKLIN
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State | VA
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Zip | 23851-1206
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Country | US
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Telephone | 757-562-2158
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Fax | 757-516-8019
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Provider Business Mailing Address
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Address Line | 19124 LAKESIDE DR
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City | COURTLAND
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State | VA
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Zip | 23837-2634
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Country | US
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Telephone | 757-562-2004
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 0024180104
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License Number State | VA
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