Provider Demographics
NPI:1093143844
Name:BROCK, AMANDA L (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:BROCK
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:659 BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2026
Mailing Address - Country:US
Mailing Address - Phone:330-602-0770
Mailing Address - Fax:330-602-0770
Practice Address - Street 1:110 DUBLIN DR STE A
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-7805
Practice Address - Country:US
Practice Address - Phone:330-364-8038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-14
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH341552363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH2298500095054Medicaid