=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336604941
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA BROCK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2019
-----------------------------------------------------
Last Update Date | 12/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 TOWN CENTER PLZ STE A
-----------------------------------------------------
City | MILL CREEK
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26280-9752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-636-0133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 247
-----------------------------------------------------
City | MILL CREEK
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26280-0247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-636-0133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN6723-NP-C
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN67253
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------