Provider Demographics
NPI:1902130800
Name:BROOKMAN, PAMELA ROBIN
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:ROBIN
Last Name:BROOKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3046 APPALOOSA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-6157
Mailing Address - Country:US
Mailing Address - Phone:928-453-8622
Mailing Address - Fax:
Practice Address - Street 1:3046 APPALOOSA DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-6157
Practice Address - Country:US
Practice Address - Phone:928-453-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ528442Medicaid