Healthcare Provider Details

I. General information

NPI: 1992712442
Provider Name (Legal Business Name): HEATHER ELLISON BROCK ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3760 PIPER ST STE 1108
ANCHORAGE AK
99508-4683
US

IV. Provider business mailing address

PO BOX 4105
PORTLAND OR
97208-4105
US

V. Phone/Fax

Practice location:
  • Phone: 907-212-6900
  • Fax: 907-212-6936
Mailing address:
  • Phone: 866-907-1068
  • Fax: 425-917-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number751
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number751
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: