Healthcare Provider Details

I. General information

NPI: 1841299500
Provider Name (Legal Business Name): NELL CATHERINE BROCK FNP,C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 VFW RD
GRENADA MS
38901
US

IV. Provider business mailing address

108 VFW RD PO BOX 1112
GRENADA MS
38902
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-6920
  • Fax: 662-226-6920
Mailing address:
  • Phone: 662-226-6920
  • Fax: 662-226-6920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR604526
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: