Provider Demographics
NPI:1801302260
Name:BROOKS, KAREN LYNNE (PCA)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LYNNE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:LYNNE
Other - Last Name:ANGELO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4807 B TENNESSEE STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309
Mailing Address - Country:US
Mailing Address - Phone:304-356-4562
Mailing Address - Fax:304-558-4563
Practice Address - Street 1:4807-B TENNESSEE STREET
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:45309
Practice Address - Country:US
Practice Address - Phone:304-356-4562
Practice Address - Fax:304-558-4563
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810020100OtherPROVIDER ID