Provider Demographics
NPI:1164881090
Name:BROOKS, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BROOKS
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 1:305 WHITTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-6585
Mailing Address - Country:US
Mailing Address - Phone:678-873-8169
Mailing Address - Fax:
Practice Address - Street 1:305 WHITTINGTON DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31216-6585
Practice Address - Country:US
Practice Address - Phone:678-873-8169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-20
Last Update Date:2016-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000475367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered