Provider Demographics
NPI:1043940018
Name:MADDIE, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:MADDIE
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 1:2211 COLLINGDALE PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3817
Mailing Address - Country:US
Mailing Address - Phone:704-989-3723
Mailing Address - Fax:
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:704-989-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program