MEDICARE: MRS. NAKLESA TONETTE BROCK FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	3013868	KY

General Provider Information

NPI Number	:	1609402429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NAKLESA TONETTE BROCK FNP-C

Provider Business Mailing Address
First Line	:	1403 CLOVERHILLS DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40216-4027
Country	:	US
Telephone Number	:	502-759-3381
Fax Number	:

Provider Business Practice Location Address
First Line	:	1403 CLOVERHILLS DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40216-4027
Country	:	US
Telephone Number	:	502-759-3381
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2020
Last Update Date	:	03/13/2020

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