Provider Demographics
NPI:1932492998
Name:BROCK, TIFFANY LEIGH (LPN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LEIGH
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 1:1089 CLAUDIA AVE
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-8431
Mailing Address - Country:US
Mailing Address - Phone:614-935-9474
Mailing Address - Fax:
Practice Address - Street 1:1089 CLAUDIA AVE
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-8431
Practice Address - Country:US
Practice Address - Phone:614-935-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.138012164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse