Provider Demographics
NPI:1497428593
Name:BROOKS, KYRA (LPN)
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 DUTCHMANS LN STE B2
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-4302
Mailing Address - Country:US
Mailing Address - Phone:410-763-9040
Mailing Address - Fax:
Practice Address - Street 1:505 DUTCHMANS LN STE B2
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-4302
Practice Address - Country:US
Practice Address - Phone:410-763-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP50180164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDNONEMedicaid