Provider Demographics
NPI:1396338240
Name:BROCK, SANDRA ANN
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:ANN
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:PO BOX 3056
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-3056
Mailing Address - Country:US
Mailing Address - Phone:509-821-1830
Mailing Address - Fax:
Practice Address - Street 1:22415 N PERRY RD
Practice Address - Street 2:
Practice Address - City:COLBERT
Practice Address - State:WA
Practice Address - Zip Code:99005-9736
Practice Address - Country:US
Practice Address - Phone:509-467-1584
Practice Address - Fax:509-467-1584
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide