Provider Demographics
NPI:1831932110
Name:BROOKS, ILEYNARET MICHELLE
Entity type:Individual
Prefix:
First Name:ILEYNARET
Middle Name:MICHELLE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ILEYNA
Other - Middle Name:
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4325 SANDY SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-5492
Mailing Address - Country:US
Mailing Address - Phone:850-238-7447
Mailing Address - Fax:
Practice Address - Street 1:1021 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-5252
Practice Address - Country:US
Practice Address - Phone:800-277-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer