Provider Demographics
NPI:1891988077
Name:ERVIN, BROOKE MICHELLE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MICHELLE
Last Name:ERVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:MICHELLE
Other - Last Name:RHODES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-9001
Mailing Address - Fax:704-316-9008
Practice Address - Street 1:1401 MATTHEWS TOWNSHIP PKWY STE 312
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105
Practice Address - Country:US
Practice Address - Phone:704-316-9001
Practice Address - Fax:704-316-9008
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC161919363L00000X
NC5003350363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1891988077OtherNPI