Provider Demographics
NPI:1710427075
Name:BROCK, TREA ANN
Entity Type:Individual
Prefix:
First Name:TREA
Middle Name:ANN
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TREA
Other - Middle Name:ANN
Other - Last Name:MCNEMAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:860 E BROAD STREET
Mailing Address - Street 2:SUITE I
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6542
Mailing Address - Country:US
Mailing Address - Phone:440-323-8515
Mailing Address - Fax:440-323-7900
Practice Address - Street 1:3700 KOLBE RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1611
Practice Address - Country:US
Practice Address - Phone:440-323-8515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH259599367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered