Provider Demographics
NPI:1265054464
Name:FERNANDEZ, BROOKE WELLS
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:WELLS
Last Name:FERNANDEZ
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 1:1601 GREENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29208-4001
Mailing Address - Country:US
Mailing Address - Phone:803-777-7412
Mailing Address - Fax:
Practice Address - Street 1:1601 GREENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-4001
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH183569363LA2200X
NC5021742363LA2200X
TX1191646363LA2200X
MARN10022445363LA2200X
PASP032330363LA2200X
MO2025002510363LA2200X
LA239843363LA2200X
SC24569363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health