Provider Demographics
NPI:1710768080
Name:BROCK, SUSAN (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
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 1:45 APPLE RD APT 21
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-5355
Mailing Address - Country:US
Mailing Address - Phone:301-693-0035
Mailing Address - Fax:
Practice Address - Street 1:75 LINDALL ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2121
Practice Address - Country:US
Practice Address - Phone:978-223-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN168400163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse