Provider Demographics
NPI:1003269192
Name:BROCK, MICHELE MARIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:MARIE
Last Name:BROCK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10530 DISCOVERY DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-3050
Mailing Address - Country:US
Mailing Address - Phone:702-802-2841
Mailing Address - Fax:
Practice Address - Street 1:5380 S RAINBOW BLVD STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1878
Practice Address - Country:US
Practice Address - Phone:702-463-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM401206363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicaid