Provider Demographics
NPI:1952129637
Name:BROCK, JOANNA LYNN (BSN, RN)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LYNN
Last Name:BROCK
Suffix:
Gender:F
Credentials:BSN, RN
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 213
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12721-0213
Mailing Address - Country:US
Mailing Address - Phone:845-741-9965
Mailing Address - Fax:
Practice Address - Street 1:2834 ROUTE 17M
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:10958-5011
Practice Address - Country:US
Practice Address - Phone:845-374-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY609896163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse