Provider Demographics
NPI:1780981472
Name:BROCK, MELISSA L (CST/CSFA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:BROCK
Suffix:
Gender:F
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:LIGHTSEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CST/CSFA
Mailing Address - Street 1:8165 MARLEY DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-4161
Mailing Address - Country:US
Mailing Address - Phone:804-624-8352
Mailing Address - Fax:
Practice Address - Street 1:8260 ATLEE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1844
Practice Address - Country:US
Practice Address - Phone:804-764-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000258246ZC0007X
246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist