Provider Demographics
NPI:1386204972
Name:MELANCON, BROOKE ALENE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALENE
Last Name:MELANCON
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 1:2840 FLORIDA BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-2721
Mailing Address - Country:US
Mailing Address - Phone:225-224-2502
Mailing Address - Fax:
Practice Address - Street 1:2840 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-2721
Practice Address - Country:US
Practice Address - Phone:225-224-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206194363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily