Provider Demographics
NPI:1104693761
Name:BROCK, KELLIE KAISER (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:KAISER
Last Name:BROCK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1571 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4161
Mailing Address - Country:US
Mailing Address - Phone:171-358-2093
Mailing Address - Fax:
Practice Address - Street 1:1571 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-4161
Practice Address - Country:US
Practice Address - Phone:713-582-0937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11029005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily