Provider Demographics
NPI:1003574500
Name:BROCK, HEATHER DAWN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:DAWN
Other - Last Name:BERNA/CALIBO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:401 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426-2066
Mailing Address - Country:US
Mailing Address - Phone:251-286-8234
Mailing Address - Fax:
Practice Address - Street 1:401 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-2066
Practice Address - Country:US
Practice Address - Phone:251-286-8234
Practice Address - Fax:251-286-8233
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015727363LF0000X
AL1-182636363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily