Provider Demographics
NPI:1326407370
Name:BROOKS, EBONIE
Entity Type:Individual
Prefix:
First Name:EBONIE
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 1:416 CRISWELL CT
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2470
Mailing Address - Country:US
Mailing Address - Phone:937-952-4532
Mailing Address - Fax:
Practice Address - Street 1:416 CRISWELL CT
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2470
Practice Address - Country:US
Practice Address - Phone:937-952-4532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN149-102164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse