Provider Demographics
NPI:1124541057
Name:BURRIS, BROCK (RN)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:BURRIS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 DOVER AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2529
Mailing Address - Country:US
Mailing Address - Phone:330-987-6707
Mailing Address - Fax:
Practice Address - Street 1:1711 DOVER AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2529
Practice Address - Country:US
Practice Address - Phone:330-987-6707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH48411163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH408411OtherRN LISCENCE