Provider Demographics
NPI:1164026977
Name:AVILA, BROOKE ANN
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:ANN
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BROOKE
Other - Middle Name:ANN
Other - Last Name:NANEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7475
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-2475
Mailing Address - Country:US
Mailing Address - Phone:907-617-6145
Mailing Address - Fax:907-885-6613
Practice Address - Street 1:2524 FIRST AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5804
Practice Address - Country:US
Practice Address - Phone:907-617-6145
Practice Address - Fax:907-885-6613
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1584706Medicaid
AK1021118Medicaid