Provider Demographics
NPI:1093981037
Name:BROOKS, SHEBA GUSTOVA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHEBA
Middle Name:GUSTOVA
Last Name:BROOKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:SHEBA
Other - Middle Name:GUSTOVA
Other - Last Name:BEAUMONT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:23588 LEE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3101
Mailing Address - Country:US
Mailing Address - Phone:313-447-7619
Mailing Address - Fax:
Practice Address - Street 1:23588 LEE LN
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-3101
Practice Address - Country:US
Practice Address - Phone:313-447-7619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703096450164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse