Provider Demographics
NPI:1639773286
Name:BROOKS, WANDA ANN
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:ANN
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 1:1555 FRANKLIN PARK S
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2107
Mailing Address - Country:US
Mailing Address - Phone:614-329-0022
Mailing Address - Fax:
Practice Address - Street 1:1555 FRANKLIN PARK S
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2107
Practice Address - Country:US
Practice Address - Phone:614-329-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0077648Medicaid
OH2560330OtherDODD CONTRACT NUMBER