Provider Demographics
NPI:1508396086
Name:BROOKS, KELLI BRI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:BRI
Last Name:BROOKS
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 1:2323 E GREENLAW LN #10-B
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:929-326-1129
Mailing Address - Fax:
Practice Address - Street 1:2323 E GREENLAW LN STE 10B
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1849
Practice Address - Country:US
Practice Address - Phone:480-318-1798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8611480174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist