Provider Demographics
NPI:1245926468
Name:GREEN, BROOKE ASHLEY
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ASHLEY
Last Name:GREEN
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 1:3215 S BROCK DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-2140
Mailing Address - Country:US
Mailing Address - Phone:405-514-0622
Mailing Address - Fax:
Practice Address - Street 1:3215 S BROCK DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-2140
Practice Address - Country:US
Practice Address - Phone:405-514-0622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR082923661175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist