Provider Demographics
NPI:1619628708
Name:BROOKS, SHERRY
Entity Type:Individual
Prefix:MISS
First Name:SHERRY
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 1:5411 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-1805
Mailing Address - Country:US
Mailing Address - Phone:131-449-3405
Mailing Address - Fax:314-480-7155
Practice Address - Street 1:5411 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-1805
Practice Address - Country:US
Practice Address - Phone:131-449-3405
Practice Address - Fax:314-480-7155
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF200359001172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO844157164Medicaid