Provider Demographics
NPI:1871108233
Name:BROCKINGTON, RICKY
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:BROCKINGTON
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 1:19124 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:COURTLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23837-2634
Mailing Address - Country:US
Mailing Address - Phone:757-562-2004
Mailing Address - Fax:
Practice Address - Street 1:102 FAIRVIEW DR STE B
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1206
Practice Address - Country:US
Practice Address - Phone:757-562-2158
Practice Address - Fax:757-516-8019
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180104363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner