Provider Demographics
NPI:1912549965
Name:HUDSON, BROOKE (FNP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:HUDSON
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 1:201 BAILEY LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1999
Mailing Address - Country:US
Mailing Address - Phone:618-435-9692
Mailing Address - Fax:618-435-9327
Practice Address - Street 1:201 BAILEY LN
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1999
Practice Address - Country:US
Practice Address - Phone:618-435-9692
Practice Address - Fax:618-435-9327
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020202363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner