Provider Demographics
NPI:1649545302
Name:BROCK, CASEY LEIGH (APN)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:LEIGH
Last Name:BROCK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 SALMON LN
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-2282
Mailing Address - Country:US
Mailing Address - Phone:501-205-8389
Mailing Address - Fax:888-480-2842
Practice Address - Street 1:2200 ADA AVE
Practice Address - Street 2:STE 203
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4985
Practice Address - Country:US
Practice Address - Phone:501-205-8389
Practice Address - Fax:888-480-2845
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03651363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health