Provider Demographics
NPI:1275052425
Name:BROCK, TAMMARA
Entity Type:Individual
Prefix:
First Name:TAMMARA
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 1:11417 CAROLINA RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-3703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11417 CAROLINA RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-3703
Practice Address - Country:US
Practice Address - Phone:216-645-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0213387Medicaid