Provider Demographics
NPI:1336730498
Name:BROOKS, CARISSA ANN
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANN
Last Name:BROOKS
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 863
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:VT
Mailing Address - Zip Code:05088-0863
Mailing Address - Country:US
Mailing Address - Phone:518-424-7648
Mailing Address - Fax:
Practice Address - Street 1:221 GILLETTE STREET
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:VT
Practice Address - Zip Code:05088-0863
Practice Address - Country:US
Practice Address - Phone:518-424-7648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical