Provider Demographics
NPI:1790783207
Name:BROOKS, SANDRA L (ARNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:BROOKS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 N NOVA RD STE 203
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4422
Mailing Address - Country:US
Mailing Address - Phone:386-672-7175
Mailing Address - Fax:386-672-0771
Practice Address - Street 1:533 N NOVA RD STE 203
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4422
Practice Address - Country:US
Practice Address - Phone:386-672-7175
Practice Address - Fax:386-672-0771
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2650922363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305058100Medicaid
FL1790783207OtherMEDICARE PTAN Y4188Y
FL305058100Medicaid
FLS02080Medicare UPIN