Provider Demographics
NPI:1467051151
Name:BROOKS, MALLORY JO (NP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:JO
Last Name:BROOKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:2221 JACKSBORO PIKE STE C4
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-3007
Practice Address - Country:US
Practice Address - Phone:423-566-3488
Practice Address - Fax:866-722-3453
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30895363LP0200X, 363LP0200X
KY3016332363LP0200X
IL202018544364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ074118Medicaid
TNQ074118Medicaid