Healthcare Provider Details

I. General information

NPI: 1558920520
Provider Name (Legal Business Name): ALLISON BROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 HOSPITAL DR
CORDELE GA
31015-3275
US

IV. Provider business mailing address

307 E 3RD AVE
CORDELE GA
31015-3208
US

V. Phone/Fax

Practice location:
  • Phone: 229-276-2000
  • Fax: 229-276-3634
Mailing address:
  • Phone: 229-271-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN167970
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: