Provider Demographics
NPI:1811430309
Name:BROCK-HUDSON, DESIREE CADELL (NP)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:CADELL
Last Name:BROCK-HUDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:CADELL
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37367-0349
Mailing Address - Country:US
Mailing Address - Phone:423-447-2994
Mailing Address - Fax:
Practice Address - Street 1:3062 MAIN ST
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37367-5746
Practice Address - Country:US
Practice Address - Phone:423-447-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21997363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily