Provider Demographics
NPI:1245066232
Name:LONG, BROOKE LYNNE (RD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LYNNE
Last Name:LONG
Suffix:
Gender:F
Credentials:RD
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 21
Mailing Address - Street 2:
Mailing Address - City:SOMERSET CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49282-0021
Mailing Address - Country:US
Mailing Address - Phone:225-361-6691
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 21
Practice Address - Street 2:
Practice Address - City:SOMERSET CENTER
Practice Address - State:MI
Practice Address - Zip Code:49282-0021
Practice Address - Country:US
Practice Address - Phone:225-361-6691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103961133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered