Provider Demographics
NPI:1073520243
Name:BROOKS, MARY LOUISE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138
Mailing Address - Country:US
Mailing Address - Phone:740-385-0924
Mailing Address - Fax:
Practice Address - Street 1:96 MILL ST
Practice Address - Street 2:
Practice Address - City:NELSONVILLE
Practice Address - State:OH
Practice Address - Zip Code:45764
Practice Address - Country:US
Practice Address - Phone:740-753-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN37394164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
2257703Medicare ID - Type Unspecified