Provider Demographics
NPI:1629315379
Name:GILLIAM, BROOKE WOOTEN (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:WOOTEN
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 BODEN WAY
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-8296
Mailing Address - Country:US
Mailing Address - Phone:336-209-7309
Mailing Address - Fax:
Practice Address - Street 1:205 BODEN WAY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-8296
Practice Address - Country:US
Practice Address - Phone:362-097-3093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC247237163W00000X
NCL-152817163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse