Provider Demographics
NPI:1093073124
Name:BROOKS, ROBERT LEE (CNA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:BROOKS
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6018 WELLBORN TRAIL
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058
Mailing Address - Country:US
Mailing Address - Phone:404-821-6121
Mailing Address - Fax:
Practice Address - Street 1:6018 WELLBORN TRAIL
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058
Practice Address - Country:US
Practice Address - Phone:404-821-6121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0030005255374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA251TOOOOOXMedicaid
GA376K00000XMedicaid
GA347C00000XMedicaid
GA372600000XMedicaid
GA374U00000XMedicaid
GA343900000XMedicaid