Provider Demographics
NPI:1891971339
Name:BROCK, KELLY (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 ELMWOOD TER
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3707
Mailing Address - Country:US
Mailing Address - Phone:585-529-4881
Mailing Address - Fax:
Practice Address - Street 1:345 ELMWOOD TER
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3707
Practice Address - Country:US
Practice Address - Phone:585-529-4881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10284460164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse