Provider Demographics
NPI:1932741840
Name:SANSOM, BROOKE REVELL (APRN)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:REVELL
Last Name:SANSOM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19611 FL-20 WEST
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424
Mailing Address - Country:US
Mailing Address - Phone:850-674-5645
Mailing Address - Fax:
Practice Address - Street 1:19611 FL-20 WEST
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424
Practice Address - Country:US
Practice Address - Phone:850-674-5645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9435556163W00000X
FL11015583363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse