Healthcare Provider Details

I. General information

NPI: 1184748063
Provider Name (Legal Business Name): CAROL ANNE MOCK FNP-CS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2007
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 S. SAN JACINTO AVE.
HEMET CA
92583
US

IV. Provider business mailing address

22400 GAVILAN RD
PERRIS CA
92570
US

V. Phone/Fax

Practice location:
  • Phone: 951-665-1440
  • Fax: 818-696-2590
Mailing address:
  • Phone: 951-780-8565
  • Fax: 951-780-7344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN235312
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberPHN48338
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN46925
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP11416
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberCNS1131
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: