Provider Demographics
NPI:1972071306
Name:DOUGLAS, BROOKE ERIN (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ERIN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 S FAIRKNOLL DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1824
Mailing Address - Country:US
Mailing Address - Phone:719-251-2186
Mailing Address - Fax:
Practice Address - Street 1:332 S ORCHARD SPRINGS DR STE 150
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81007-6154
Practice Address - Country:US
Practice Address - Phone:719-253-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-03
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO201810523363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics