Healthcare Provider Details

I. General information

NPI: 1336604941
Provider Name (Legal Business Name): SARA BROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 TOWN CENTER PLZ
MILL CREEK WV
26280-9752
US

IV. Provider business mailing address

PO BOX 247
MILL CREEK WV
26280-0247
US

V. Phone/Fax

Practice location:
  • Phone: 304-636-0133
  • Fax:
Mailing address:
  • Phone: 304-636-0133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN67253
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN6723-NP-C
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: