Provider Demographics
NPI:1437503273
Name:SHORES, BROOKE LYNN
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:LYNN
Last Name:SHORES
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 1:1101 VINE ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-2126
Mailing Address - Country:US
Mailing Address - Phone:570-344-6177
Mailing Address - Fax:
Practice Address - Street 1:1101 VINE ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2126
Practice Address - Country:US
Practice Address - Phone:570-344-6177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC014679225X00000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist