Provider Demographics
NPI:1063021749
Name:HARRIS, BROOKE NICOLE (CST, BS, AA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CST, BS, AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 E VISTA RIDGE MALL DR APT 4933
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-4024
Mailing Address - Country:US
Mailing Address - Phone:318-834-6284
Mailing Address - Fax:
Practice Address - Street 1:355 E VISTA RIDGE MALL DR APT 4933
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-4024
Practice Address - Country:US
Practice Address - Phone:318-834-6284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA118694208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery