Provider Demographics
NPI:1730500430
Name:BROCK, SUSAN MICHELLE (NP)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:MICHELLE
Last Name:BROCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MICHELLE
Other - Last Name:SLAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGPCNP-BC
Mailing Address - Street 1:1925 ASHLAND CITY RD
Mailing Address - Street 2:APT 207
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5296
Mailing Address - Country:US
Mailing Address - Phone:931-801-0502
Mailing Address - Fax:
Practice Address - Street 1:LIFELINE COMMUNITY HEALTHCARE
Practice Address - Street 2:6150 OAK TREE BLVD STE 200
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131
Practice Address - Country:US
Practice Address - Phone:800-897-9177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-23
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011567363L00000X
TN22668363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000855421OtherANTHEM
IN201209630Medicaid
OH0099280Medicaid
IN201209630Medicaid