Provider Demographics
NPI:1790388072
Name:BROOKS, MALLORY REGAN
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:REGAN
Last Name:BROOKS
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 1:8654 KIRKLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-9390
Mailing Address - Country:US
Mailing Address - Phone:614-935-1990
Mailing Address - Fax:
Practice Address - Street 1:26737 NAWASH DR
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5464
Practice Address - Country:US
Practice Address - Phone:614-935-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty