Provider Demographics
NPI:1336462712
Name:BROCK, AMANDA S (ANP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:BROCK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 SIDNEY ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7203
Mailing Address - Country:US
Mailing Address - Phone:870-262-2000
Mailing Address - Fax:
Practice Address - Street 1:1215 SIDNEY ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7203
Practice Address - Country:US
Practice Address - Phone:870-262-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03334ANP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA03334ANPOtherLICENSE