Provider Demographics
NPI:1184430373
Name:MOUNTS, BROOKE NICOLE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:MOUNTS
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:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:MATEWAN
Mailing Address - State:WV
Mailing Address - Zip Code:25678-0723
Mailing Address - Country:US
Mailing Address - Phone:502-472-1304
Mailing Address - Fax:
Practice Address - Street 1:1609 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3006
Practice Address - Country:US
Practice Address - Phone:304-443-4562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY206388164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse