Provider Demographics
NPI:1518475656
Name:GARNER, BROOKE LACY
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LACY
Last Name:GARNER
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 1:2550 PARR AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2033
Mailing Address - Country:US
Mailing Address - Phone:731-325-5678
Mailing Address - Fax:731-325-5679
Practice Address - Street 1:2550 PARR AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-325-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNF12170551363LP2300X
TN23738363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily