Provider Demographics
NPI:1497071658
Name:BROCK, TESHAMA NICHOLE (RN)
Entity Type:Individual
Prefix:MRS
First Name:TESHAMA
Middle Name:NICHOLE
Last Name:BROCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:TESHAMA
Other - Middle Name:NICHOLE
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7445 SW 168TH ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-4814
Mailing Address - Country:US
Mailing Address - Phone:321-412-7129
Mailing Address - Fax:
Practice Address - Street 1:6200 SW 73RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4679
Practice Address - Country:US
Practice Address - Phone:786-662-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200942602RN163W00000X
FLRN 9291520163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse