Provider Demographics
NPI:1053093997
Name:BROCKLEHURST, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BROCKLEHURST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 VICTORIA
Mailing Address - Street 2:
Mailing Address - City:POINT EDWARD
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N7V1H6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 VICTORIA
Practice Address - Street 2:
Practice Address - City:POINT EDWARD
Practice Address - State:ONTARIO
Practice Address - Zip Code:N7V1H6
Practice Address - Country:CA
Practice Address - Phone:519-381-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.507894163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse