Provider Demographics
NPI:1578779815
Name:BROOKY, CINDY I
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:
Last Name:BROOKY
Suffix:I
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 1:1399 COUNTY ROAD 658
Mailing Address - Street 2:
Mailing Address - City:NOVA
Mailing Address - State:OH
Mailing Address - Zip Code:44859-9741
Mailing Address - Country:US
Mailing Address - Phone:419-962-4625
Mailing Address - Fax:
Practice Address - Street 1:1399 COUNTY ROAD 658
Practice Address - Street 2:
Practice Address - City:NOVA
Practice Address - State:OH
Practice Address - Zip Code:44859-9741
Practice Address - Country:US
Practice Address - Phone:419-962-4625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.100326164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2162332Medicaid