Provider Demographics
NPI:1740759950
Name:BROOKS, TANISHA (FNP)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14611 BROTHERLY LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7876
Mailing Address - Country:US
Mailing Address - Phone:704-307-9900
Mailing Address - Fax:
Practice Address - Street 1:301 S CHURCH ST STE 238
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-5755
Practice Address - Country:US
Practice Address - Phone:252-228-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC175327163W00000X
NC5012145363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse