Provider Demographics
NPI:1740613397
Name:PRINE, BROOKE ELIZABETH (IDMT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
Last Name:PRINE
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 E STONE PATH ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-9395
Mailing Address - Country:US
Mailing Address - Phone:937-430-4451
Mailing Address - Fax:
Practice Address - Street 1:57950 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-759-5116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians