Provider Demographics
NPI:1154219947
Name:BROCK, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BROCK
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:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664-1045
Mailing Address - Country:US
Mailing Address - Phone:907-224-5257
Mailing Address - Fax:907-224-7081
Practice Address - Street 1:302 RAILWAY AVE
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664-0999
Practice Address - Country:US
Practice Address - Phone:907-224-5257
Practice Address - Fax:907-224-7081
Is Sole Proprietor?:No
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK208454164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse