Provider Demographics
NPI:1497071658
Name:BROCK, TESHAMA NICHOLE (RN)
Entity type:Individual
Prefix:MRS
First Name:TESHAMA
Middle Name:NICHOLE
Last Name:BROCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:TESHAMA
Other - Middle Name:NICHOLE
Other - Last Name:BOUIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:18208 SE 246TH ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4853
Mailing Address - Country:US
Mailing Address - Phone:253-209-4591
Mailing Address - Fax:
Practice Address - Street 1:1313 BROADWAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3400
Practice Address - Country:US
Practice Address - Phone:253-209-4591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200942602RN163W00000X
FLRN 9291520163W00000X
WARN60174365163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse