Provider Demographics
NPI:1538359310
Name:HEATHER BROCK, INC
Entity type:Organization
Organization Name:HEATHER BROCK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-550-6456
Mailing Address - Street 1:2521 E MOUNTAIN VILLAGE STE B
Mailing Address - Street 2:PMB242
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7374
Mailing Address - Country:US
Mailing Address - Phone:907-373-5015
Mailing Address - Fax:907-373-7015
Practice Address - Street 1:851 E WESTPOINT DR STE 302
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7183
Practice Address - Country:US
Practice Address - Phone:907-373-5015
Practice Address - Fax:907-373-7015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK751363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP8919Medicaid