Provider Demographics
NPI:1407291925
Name:BROCK, CHASITY COWART (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:CHASITY
Middle Name:COWART
Last Name:BROCK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:CHASITY
Other - Middle Name:
Other - Last Name:COWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:222 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-1519
Mailing Address - Country:US
Mailing Address - Phone:770-537-1234
Mailing Address - Fax:770-537-1237
Practice Address - Street 1:222 GORDON ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-1519
Practice Address - Country:US
Practice Address - Phone:770-537-1234
Practice Address - Fax:770-537-1234
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177270363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily