Provider Demographics
NPI:1548625114
Name:BROCK, VIRGINIA ANNETTE (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:ANNETTE
Last Name:BROCK
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23208 LILLISTON AVE
Mailing Address - Street 2:
Mailing Address - City:ACCOMAC
Mailing Address - State:VA
Mailing Address - Zip Code:23301
Mailing Address - Country:US
Mailing Address - Phone:770-378-0795
Mailing Address - Fax:
Practice Address - Street 1:19056 GREENBUSH RD
Practice Address - Street 2:
Practice Address - City:PARKSLEY
Practice Address - State:VA
Practice Address - Zip Code:23421
Practice Address - Country:US
Practice Address - Phone:757-655-1260
Practice Address - Fax:757-665-4015
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN114139363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health