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General NPI Number Information
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NPI Number | 1407932387
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Entity Type | Individual
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Provider Name | LA WANNA WALLEN BROCK F.N.P., A.P.N.
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Gender | Female
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Dates
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Enumeration Date | 10/31/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1442 NORTH BROAD STREET SUITE 7
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City | TAZEWELL
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State | TN
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Zip | 37879
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Country | US
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Telephone | 423-626-6145
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Fax | 423-526-2804
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Provider Business Mailing Address
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Address Line | 1037 OLD JACKSBORO RD
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City | CUMBERLAND GAP
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State | TN
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Zip | 37724-4444
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Country | US
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Telephone | 423-626-6145
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Fax | 423-526-2804
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APN6601
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License Number State | TN
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