Provider Demographics
NPI:1033791504
Name:BROCKINGTON, SUZETTE
Entity Type:Individual
Prefix:
First Name:SUZETTE
Middle Name:
Last Name:BROCKINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 BENSON ST
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-3014
Mailing Address - Country:US
Mailing Address - Phone:813-562-4565
Mailing Address - Fax:813-354-4490
Practice Address - Street 1:321 BENSON ST
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-3014
Practice Address - Country:US
Practice Address - Phone:813-562-4565
Practice Address - Fax:813-354-4490
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-24
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No372600000XNursing Service Related ProvidersAdult Companion
No376K00000XNursing Service Related ProvidersNurse's Aide
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014362400Medicaid