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General NPI Number Information
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NPI Number | 1053657098
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Entity Type | Organization
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Legal Business Name | MY PRACTITONER FAMILY PRACTICE
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Dates
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Enumeration Date | 12/19/2012
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Last Update Date | 07/19/2013
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Provider Practice Location Address
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Address Line | 2996 STATE ROUTE 132
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City | AMELIA
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State | OH
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Zip | 45102-2404
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Country | US
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Telephone | 513-748-0874
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Fax | 513-322-7989
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Provider Business Mailing Address
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Address Line | 2996 STATE ROUTE 132
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City | AMELIA
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State | OH
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Zip | 45102-2404
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Country | US
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Telephone | 513-748-0874
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Fax | 513-322-7989
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Authorized Official
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Title or Position | OWNER
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Name | KATHY SUE BROCK
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Credential | NP
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Telephone | 513-748-0874
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 364SF0001X
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Taxonomy Name | Family Health Clinical Nurse Specialist
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License Number | COA.13223-NP
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License Number State | OH
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