Provider Demographics
NPI:1720026891
Name:BROCK, LINDA S (CRNA)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:S
Last Name:BROCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 HAMPTON WAY
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-6319
Mailing Address - Country:US
Mailing Address - Phone:334-792-1239
Mailing Address - Fax:
Practice Address - Street 1:36 HAMPTON WAY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-6319
Practice Address - Country:US
Practice Address - Phone:334-792-1239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-056985367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000073985Medicaid
AL000073985Medicare PIN
ALR36099Medicare UPIN