Provider Demographics
NPI:1437831476
Name:SEVERANCE, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:SEVERANCE
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 1:1448 10TH AVENUE
Mailing Address - Street 2:STE 304
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3579
Mailing Address - Country:US
Mailing Address - Phone:304-733-8728
Mailing Address - Fax:304-691-8591
Practice Address - Street 1:2211 3RD AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1225
Practice Address - Country:US
Practice Address - Phone:304-691-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3059363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant