Provider Demographics
NPI:1184928061
Name:BROCK, SHELLEY RENEE (LPN)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:RENEE
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 1:9 PARKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-2806
Mailing Address - Country:US
Mailing Address - Phone:518-253-7612
Mailing Address - Fax:
Practice Address - Street 1:9 PARKWOOD ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-2806
Practice Address - Country:US
Practice Address - Phone:518-253-7612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287102-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse