Healthcare Provider Details

I. General information

NPI: 1972091981
Provider Name (Legal Business Name): RACHEL LYNN BROCK-CHILDRESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 BALL PARK RD
HARLAN KY
40831-1701
US

IV. Provider business mailing address

120 COUNTY PIKE
HARLAN KY
40831-7023
US

V. Phone/Fax

Practice location:
  • Phone: 606-573-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3012818
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3012818
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1118656
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: