Basic Information
Provider Information | |||||||||
NPI: | 1619972478 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROCK | ||||||||
FirstName: | KYMBERLI | ||||||||
MiddleName: | RAYE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3841 PIPER ST | ||||||||
Address2: | SUITE T100 | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995084624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075613211 | ||||||||
FaxNumber: | 9075627547 | ||||||||
Practice Location | |||||||||
Address1: | 3841 PIPER ST | ||||||||
Address2: | SUITE T100 | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995084624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075613211 | ||||||||
FaxNumber: | 9075627547 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2005 | ||||||||
LastUpdateDate: | 10/29/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | NP-586A | ID | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 1073 | AK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 000010147885 | 01 |   | BLUE SHIELD | OTHER | 1022256 | 05 | AK |   | MEDICAID | 806735600 | 05 | ID |   | MEDICAID |