Provider Demographics
NPI:1568560027
Name:BENTON, BROOKE SPROUSE (MS RD LPN CDE)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:SPROUSE
Last Name:BENTON
Suffix:
Gender:F
Credentials:MS RD LPN CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 COLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540
Mailing Address - Country:US
Mailing Address - Phone:910-347-2154
Mailing Address - Fax:910-347-2789
Practice Address - Street 1:612 COLLEGE STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540
Practice Address - Country:US
Practice Address - Phone:910-347-2154
Practice Address - Fax:910-347-2789
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002187133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00156469OtherRAILROAD
NCP00156469OtherRAILROAD