Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 114762 | NC |
NPI | 1003351206 |
---|---|
Provider Name | Wendy Lynn Brock |
First Address | Fayetteville, NC 28309-0908 |
Second Address | Fayetteville, NC 28304-3424 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2016 |
Last Update Date | 23/12/2016 |