Provider Demographics
NPI:1861369183
Name:BROOKS, STACIE ANDREA
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:ANDREA
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:M
Other - Last Name:SOLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4410 STACKS RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-2758
Mailing Address - Country:US
Mailing Address - Phone:678-437-5241
Mailing Address - Fax:
Practice Address - Street 1:4410 STACKS RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-2758
Practice Address - Country:US
Practice Address - Phone:678-437-5241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath