Provider Demographics
NPI:1184748063
Name:MOCK, CAROL ANNE (FNP-CS)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANNE
Last Name:MOCK
Suffix:
Gender:F
Credentials:FNP-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22400 GAVILAN RD
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570
Mailing Address - Country:US
Mailing Address - Phone:951-780-8565
Mailing Address - Fax:951-780-7344
Practice Address - Street 1:1695 S. SAN JACINTO AVE.
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92583
Practice Address - Country:US
Practice Address - Phone:951-665-1440
Practice Address - Fax:818-696-2590
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN235312163W00000X
CAPHN48338163WC1500X
CAVN46925164X00000X
CANP11416363LF0000X
CACNS1131364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP05872Medicare UPIN