Provider Demographics
NPI:1679242747
Name:BROCK, LEANDRA SUE (RN)
Entity Type:Individual
Prefix:
First Name:LEANDRA
Middle Name:SUE
Last Name:BROCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4918 W 28TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-3302
Mailing Address - Country:US
Mailing Address - Phone:918-231-9416
Mailing Address - Fax:
Practice Address - Street 1:4918 W 28TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-3302
Practice Address - Country:US
Practice Address - Phone:918-231-9416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0123537163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical