Provider Demographics
NPI:1609419068
Name:SMITH, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:SMITH
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 1:6913 RAVEN LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4257
Mailing Address - Country:US
Mailing Address - Phone:443-878-6071
Mailing Address - Fax:
Practice Address - Street 1:620 W LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1508
Practice Address - Country:US
Practice Address - Phone:443-878-6071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant