MEDICARE: AMANDA L BROCK MSN, APRN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	341552	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093143844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA L BROCK MSN, APRN, FNP-C

Provider Business Mailing Address
First Line	:	659 BOULEVARD ST
Second Line	:
City	:	DOVER
State	:	OH
Zip	:	44622-2026
Country	:	US
Telephone Number	:	330-602-0770
Fax Number	:	330-602-0770

Provider Business Practice Location Address
First Line	:	110 DUBLIN DR STE A
Second Line	:
City	:	DOVER
State	:	OH
Zip	:	44622-7805
Country	:	US
Telephone Number	:	330-364-8038
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2013
Last Update Date	:	05/22/2019

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