Provider Demographics
NPI:1114078896
Name:BROCK, KRISTINA FAITH (CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:FAITH
Last Name:BROCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:FAITH
Other - Last Name:DOWNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:2ND FLOOR ANESTHESIA DEPT
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5611
Practice Address - Country:US
Practice Address - Phone:864-455-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3089367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1542Medicaid