| Doctor Name: | LA WANNA WALLEN BROCK |
| NPI Number: | 1407932387 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | F.N.P., A.P.N. |
| License Number: | APN6601 |
| Business Practice Address: | 1442 North Broad Street Suite 7 Tazewell, TN - 37879 |
| Business Phone Number: | 4236266145 |
| Business Fax Number: | 4235262804 |
| Mailing Address: | 1037 Old Jacksboro Rd, CUMBERLAND GAP |
| State: | TN |
| Postal Code: | 377244444 |
| Phone Number: | 4236266145 |
| Fax Number: | 4235262804 |
| NPI Enumeration Date: | 10/31/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | APN6601 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TN |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |