Provider Demographics
NPI:1780682179
Name:BAMBIC, BROOKS A (RN)
Entity Type:Individual
Prefix:MRS
First Name:BROOKS
Middle Name:A
Last Name:BAMBIC
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4388 WRIGHT RD.
Mailing Address - Street 2:
Mailing Address - City:LAURA
Mailing Address - State:OH
Mailing Address - Zip Code:45337
Mailing Address - Country:US
Mailing Address - Phone:937-248-4721
Mailing Address - Fax:
Practice Address - Street 1:4388 WRIGHT RD.
Practice Address - Street 2:
Practice Address - City:LAURA
Practice Address - State:OH
Practice Address - Zip Code:45337
Practice Address - Country:US
Practice Address - Phone:937-248-4721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN084533164W00000X
OH517867163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2090900Medicaid