Provider Demographics
NPI:1750600854
Name:BROCK, SUE MASIELLO (APRN)
Entity type:Individual
Prefix:MS
First Name:SUE
Middle Name:MASIELLO
Last Name:BROCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17920 GULF BLVD APT 101
Mailing Address - Street 2:
Mailing Address - City:REDINGTON SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33708-1194
Mailing Address - Country:US
Mailing Address - Phone:813-546-5196
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:866-686-2504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 915972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily