Provider Demographics
NPI:1720453111
Name:KRISTIN BROOKS PMHNP LLC
Entity Type:Organization
Organization Name:KRISTIN BROOKS PMHNP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:541-350-6913
Mailing Address - Street 1:1805 NE BERG WAY
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:965 SW EMKAY DR
Practice Address - Street 2:STE. 200
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3598
Practice Address - Country:US
Practice Address - Phone:541-350-6913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050080NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty