Provider Demographics
NPI:1366027393
Name:BROOKS, SAMANTHA JOANNE (CSA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOANNE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 SHETLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-7654
Mailing Address - Country:US
Mailing Address - Phone:270-792-8020
Mailing Address - Fax:
Practice Address - Street 1:1801 ASHLEY CIR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3362
Practice Address - Country:US
Practice Address - Phone:270-793-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5225246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant