Provider Demographics
NPI:1568776433
Name:BROCKE, RUBY A
Entity Type:Individual
Prefix:MS
First Name:RUBY
Middle Name:A
Last Name:BROCKE
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 1:5920 PINEWILD DRIVE
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9723
Mailing Address - Country:US
Mailing Address - Phone:614-865-0579
Mailing Address - Fax:
Practice Address - Street 1:5920 PINE WILD DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-9723
Practice Address - Country:US
Practice Address - Phone:614-865-0579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSV105660164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse