Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 1-182636 | AL |
Y | 207Q00000X | Family Doctor | 11015727 | FL |
NPI | 1003574500 |
---|---|
Provider Name | Heather Dawn Brock |
First Address | Brewton, AL 36426-2066 |
Second Address | Brewton, AL 36426-2066 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2021 |
Last Update Date | 18/01/2022 |