Provider Demographics
NPI:1790327443
Name:BROCK, KRYSTIAN NICOLE (LVN)
Entity Type:Individual
Prefix:
First Name:KRYSTIAN
Middle Name:NICOLE
Last Name:BROCK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 SE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76067-5738
Mailing Address - Country:US
Mailing Address - Phone:940-468-9691
Mailing Address - Fax:
Practice Address - Street 1:602 SE 28TH AVE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-5738
Practice Address - Country:US
Practice Address - Phone:940-468-9691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX321360164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse