Provider Demographics
NPI:1548389752
Name:SHROCK, MARCIA LYNNE (APRN)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:LYNNE
Last Name:SHROCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 N WATTERSON TRL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2700
Mailing Address - Country:US
Mailing Address - Phone:502-314-7050
Mailing Address - Fax:502-245-7992
Practice Address - Street 1:122 N WATTERSON TRL
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2700
Practice Address - Country:US
Practice Address - Phone:502-314-7050
Practice Address - Fax:502-245-7992
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5009232363LA2200X
OR201505322NP-PP363LA2200X
MECNP151106363LA2200X
SC18795363LA2200X
IN99063696A363LA2200X
TX124312363LA2200X
NM02529363LA2200X
OHCOA.14296-NP363LP2300X
KY3004426363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC18795OtherSTATE ARNP LICENSE
OR201504071RNOtherOR RN LICENSE
OR201505322NP-PPOtherOR NP LICENSE
KY3004426OtherSTATE APRN LICENSE
OHCOA.14296-NPOtherSTATE NP LICENSE
NC5009232OtherNC NP LICENSE
KY7100214550Medicaid
IN71005296AOtherIN NP LICENSE
MECNP151106OtherNP LICENSE
NMCNP-02529OtherSTATE ARNP LICENSE
TXAP124312OtherSTATE ARNP LICENSE