Provider Demographics
NPI:1083386460
Name:LEWIS, BROOKE BARLOW
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:BARLOW
Last Name:LEWIS
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 1:455 W 2025 N
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2602
Mailing Address - Country:US
Mailing Address - Phone:801-635-6778
Mailing Address - Fax:
Practice Address - Street 1:94 E PAGES LN STE A
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-2216
Practice Address - Country:US
Practice Address - Phone:801-294-0578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program