Provider Demographics
NPI:1154094084
Name:BROCKNER, DELORIS ANN (RN, LMT)
Entity Type:Individual
Prefix:
First Name:DELORIS
Middle Name:ANN
Last Name:BROCKNER
Suffix:
Gender:F
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2946 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-3140
Mailing Address - Country:US
Mailing Address - Phone:850-526-3211
Mailing Address - Fax:
Practice Address - Street 1:2946 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-3140
Practice Address - Country:US
Practice Address - Phone:850-526-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA90046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8506939625OtherNON BILLABLE