Provider Demographics
NPI:1003269192
Name:BROCK, MICHELE MARIE (NP)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:MARIE
Last Name:BROCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 HILL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-2744
Mailing Address - Country:US
Mailing Address - Phone:269-273-8511
Mailing Address - Fax:
Practice Address - Street 1:1021 HILL ST STE 100
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-2744
Practice Address - Country:US
Practice Address - Phone:269-273-8511
Practice Address - Fax:269-273-7413
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM401206363L00000X
MI4704196390363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicaid