Provider Demographics
NPI:1245507839
Name:BROOKS, CICELY SIMONE (PA- C)
Entity type:Individual
Prefix:
First Name:CICELY
Middle Name:SIMONE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PA- C
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8543 W 102ND TER
Mailing Address - Street 2:BUILDING 4, APT 313
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1347
Mailing Address - Country:US
Mailing Address - Phone:773-824-6005
Mailing Address - Fax:
Practice Address - Street 1:4177 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-1849
Practice Address - Country:US
Practice Address - Phone:773-932-1142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-26
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085.004015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant