Provider Demographics
NPI:1265666093
Name:FAIR, BROOKE L (FNP)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:L
Last Name:FAIR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 S. NATIONAL AVE
Mailing Address - Street 2:STE. 540
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5284
Mailing Address - Country:US
Mailing Address - Phone:417-269-2490
Mailing Address - Fax:417-269-2492
Practice Address - Street 1:816 E. MAIN
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-1597
Practice Address - Country:US
Practice Address - Phone:417-269-2490
Practice Address - Fax:417-269-2492
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO154917363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26-8535OtherRH MEDICARE
MO1265666093Medicaid
MO26D0889777OtherCLIA
MO597780303OtherRH MEDICAID
MO26D0889777OtherCLIA
MO26-8535OtherRH MEDICARE
263967Medicare Oscar/Certification