Provider Demographics
NPI:1508614892
Name:SHANK, BROOKLYN PAIGE
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:PAIGE
Last Name:SHANK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROOKLYN
Other - Middle Name:PAIGE
Other - Last Name:GOTTFRIED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1720 OHIOHEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-9253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1720 OHIOHEALTH WAY FL 2
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-9253
Practice Address - Country:US
Practice Address - Phone:567-309-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0036394363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily