Healthcare Provider Details

I. General information

NPI: 1609601699
Provider Name (Legal Business Name): SAMANTHA ELIZABETH BROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2024
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 NUCKOLLS RD
BOLIVAR TN
38008-1599
US

IV. Provider business mailing address

629 NUCKOLLS RD
BOLIVAR TN
38008-1599
US

V. Phone/Fax

Practice location:
  • Phone: 731-658-3388
  • Fax:
Mailing address:
  • Phone: 731-658-3388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number42277
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: