Provider Demographics
NPI:1124531678
Name:BROCK, FALISSEONA O (QBHP)
Entity type:Individual
Prefix:
First Name:FALISSEONA
Middle Name:O
Last Name:BROCK
Suffix:
Gender:F
Credentials:QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:3201 W. KEISER AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3467
Practice Address - Country:US
Practice Address - Phone:870-622-0592
Practice Address - Fax:870-622-0782
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator