Provider Demographics
NPI:1689256380
Name:DOUGLAS, BROOKLYN HELENE
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:HELENE
Last Name:DOUGLAS
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 1:3455 KEARNY VILLA RD APT 432
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1985
Mailing Address - Country:US
Mailing Address - Phone:925-960-3262
Mailing Address - Fax:
Practice Address - Street 1:1031 25TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2102
Practice Address - Country:US
Practice Address - Phone:619-232-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program