Provider Demographics
NPI:1639450315
Name:BROCK, JULIANNE FLORENCE (FNP)
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:FLORENCE
Last Name:BROCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JULIANNE
Other - Middle Name:FLORENCE
Other - Last Name:MAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:16770 SW EDY RD STE 102
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9679
Practice Address - Country:US
Practice Address - Phone:503-216-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150104NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily