Provider Demographics
NPI:1649941071
Name:BROCK, NATALIE (FNP)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1072 N LIBERTY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8963
Mailing Address - Country:US
Mailing Address - Phone:208-302-4600
Mailing Address - Fax:
Practice Address - Street 1:1072 N LIBERTY ST STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8963
Practice Address - Country:US
Practice Address - Phone:208-302-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID69978363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily