Provider Demographics
NPI:1649632068
Name:BROOKS, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BROOKS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 E MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-1224
Mailing Address - Country:US
Mailing Address - Phone:217-553-2548
Mailing Address - Fax:
Practice Address - Street 1:5850 6TH STREET FRONTAGE RD E STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5194
Practice Address - Country:US
Practice Address - Phone:217-529-5046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014117363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology