Provider Demographics
NPI:1801364245
Name:BROCK, TRACY (FNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S CENTRAL AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-4196
Mailing Address - Country:US
Mailing Address - Phone:715-898-1298
Mailing Address - Fax:
Practice Address - Street 1:630 S CENTRAL AVE STE 303
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-4196
Practice Address - Country:US
Practice Address - Phone:715-898-1298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8804-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily