Provider Demographics
NPI:1619972478
Name:BROCK, KYMBERLI RAYE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:KYMBERLI
Middle Name:RAYE
Last Name:BROCK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 PIPER ST
Mailing Address - Street 2:SUITE T100
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4624
Mailing Address - Country:US
Mailing Address - Phone:907-561-3211
Mailing Address - Fax:907-562-7547
Practice Address - Street 1:3841 PIPER ST
Practice Address - Street 2:SUITE T100
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4624
Practice Address - Country:US
Practice Address - Phone:907-561-3211
Practice Address - Fax:907-562-7547
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-586A363LA2200X
AK1073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010147885OtherBLUE SHIELD
AK1022256Medicaid
ID806735600Medicaid
AKK162319Medicare PIN
000010147885OtherBLUE SHIELD
ID806735600Medicaid