Provider Demographics
NPI:1134381601
Name:BROCK, SANDRA ALLENE
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:ALLENE
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 1:101 TWILIGHT ST NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1151
Mailing Address - Country:US
Mailing Address - Phone:321-984-0430
Mailing Address - Fax:
Practice Address - Street 1:101 TWILIGHT ST NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1151
Practice Address - Country:US
Practice Address - Phone:321-984-0430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230526700OtherFLORIDA MEDICAID PROVIDER NUMBER