Provider Demographics
NPI:1881855468
Name:BROCK, JOANN ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:ELIZABETH
Last Name:BROCK
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 1:51 BLARE CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-7380
Mailing Address - Country:US
Mailing Address - Phone:386-447-8438
Mailing Address - Fax:386-447-8438
Practice Address - Street 1:51 BLARE CASTLE DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-7380
Practice Address - Country:US
Practice Address - Phone:386-447-8438
Practice Address - Fax:386-447-8438
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL680544296Medicaid