Provider Demographics
NPI:1851773865
Name:BROCK, MARY GUION (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GUION
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 1:1290 SILAS DEANE HIGHWAY
Mailing Address - Street 2:HHC - CVO
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1646
Practice Address - Country:US
Practice Address - Phone:860-696-2200
Practice Address - Fax:860-561-0001
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8190363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily