Basic Information
| Provider Information | |||||||||
| NPI: | 1992712442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | ELLISON | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4105 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669071068 | ||||||||
| FaxNumber: | 4259179141 | ||||||||
| Practice Location | |||||||||
| Address1: | 3760 PIPER ST STE 1108 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072126900 | ||||||||
| FaxNumber: | 9072126936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 751 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363L00000X | 751 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1023124 | 05 | AK | MEDICAID |