Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | 2012037998 | MO |
NPI | 1013350271 |
---|---|
Provider Name | Mrs. Angela M Brock |
First Address | Saint Louis, MO 63125-4181 |
Second Address | Saint Louis, MO 63125-4181 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/04/2013 |
Last Update Date | 08/04/2013 |