Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 5008863 | NC |
NPI | 1003362161 |
---|---|
Provider Name | Mary Brock |
First Address | Charlotte, NC 28219-9305 |
Second Address | Lincolnton, NC 28092-4114 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/08/2016 |
Last Update Date | 27/09/2021 |