Healthcare Provider Details

I. General information

NPI: 1649545302
Provider Name (Legal Business Name): CASEY LEIGH BROCK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 ADA AVE STE 203
CONWAY AR
72034-4985
US

IV. Provider business mailing address

198 SALMON LN
RUSSELLVILLE AR
72802-2282
US

V. Phone/Fax

Practice location:
  • Phone: 501-205-8389
  • Fax: 888-480-2845
Mailing address:
  • Phone: 501-205-8389
  • Fax: 888-480-2842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA03651
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: