Provider Demographics
NPI:1558077982
Name:BROOKS, DESTINI
Entity Type:Individual
Prefix:
First Name:DESTINI
Middle Name:
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 1:5193 OLIVE RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-1423
Mailing Address - Country:US
Mailing Address - Phone:937-537-3607
Mailing Address - Fax:
Practice Address - Street 1:5193 OLIVE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-1423
Practice Address - Country:US
Practice Address - Phone:937-537-3607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHVS700661Medicaid