Provider Demographics
NPI:1336604941
Name:BROCK, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:26280-0247
Mailing Address - Country:US
Mailing Address - Phone:304-636-0133
Mailing Address - Fax:
Practice Address - Street 1:46 TOWN CENTER PLZ STE A
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WV
Practice Address - Zip Code:26280-9752
Practice Address - Country:US
Practice Address - Phone:304-636-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN6723-NP-C363LF0000X
WVAPRN67253363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily