Provider Demographics
NPI:1871640292
Name:BROCK, DOREEN (CFNP)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533-0475
Mailing Address - Country:US
Mailing Address - Phone:228-374-2494
Mailing Address - Fax:228-374-0856
Practice Address - Street 1:1046 DIVISION STREET
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530
Practice Address - Country:US
Practice Address - Phone:228-374-2494
Practice Address - Fax:228-374-0856
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851826363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01570890Medicaid
MS01570890Medicaid