Healthcare Provider Details

I. General information

NPI: 1811430309
Provider Name (Legal Business Name): DESIREE CADELL BROCK-HUDSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DESIREE CADELL SMITH

II. Dates (important events)

Enumeration Date: 12/01/2016
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3062 MAIN ST
PIKEVILLE TN
37367-5746
US

IV. Provider business mailing address

PO BOX 349
PIKEVILLE TN
37367-0349
US

V. Phone/Fax

Practice location:
  • Phone: 423-447-2955
  • Fax:
Mailing address:
  • Phone: 423-447-2994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21997
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: