Provider Demographics
NPI:1154676716
Name:BROOKS, BRADLEY JUSTIN (RN)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JUSTIN
Last Name:BROOKS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:HOLLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14470-1060
Mailing Address - Country:US
Mailing Address - Phone:585-414-8637
Mailing Address - Fax:
Practice Address - Street 1:34 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:HOLLEY
Practice Address - State:NY
Practice Address - Zip Code:14470-1060
Practice Address - Country:US
Practice Address - Phone:585-414-8637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY658252163W00000X
NY295277164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse