Provider Demographics
NPI:1083357651
Name:BROCK, MEGAN LEE (PMNHP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LEE
Last Name:BROCK
Suffix:
Gender:F
Credentials:PMNHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5238
Mailing Address - Country:US
Mailing Address - Phone:209-608-0422
Mailing Address - Fax:
Practice Address - Street 1:2498 N STOKESBERRY PL STE 170
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5842
Practice Address - Country:US
Practice Address - Phone:208-918-0958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2021210021363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health