Provider Demographics
NPI:1275269623
Name:RANDOL, BROOKE (MSN, RN, AGCNS-BC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:RANDOL
Suffix:
Gender:F
Credentials:MSN, RN, AGCNS-BC
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-6070
Practice Address - Fax:260-373-6704
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28195468A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist