Provider Demographics
NPI:1700391380
Name:WARNER, BROOKEMADISON OLUFUNKE
Entity Type:Individual
Prefix:
First Name:BROOKEMADISON
Middle Name:OLUFUNKE
Last Name:WARNER
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 1:1081 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-5508
Mailing Address - Country:US
Mailing Address - Phone:907-978-7693
Mailing Address - Fax:
Practice Address - Street 1:1081 AURORA DR
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5508
Practice Address - Country:US
Practice Address - Phone:907-978-7693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1062877251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health