Provider Demographics
NPI:1952370223
Name:BROOKS, IDERIA (LICENSED PRACTICAL N)
Entity Type:Individual
Prefix:MS
First Name:IDERIA
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 N PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2553
Mailing Address - Country:US
Mailing Address - Phone:414-263-1579
Mailing Address - Fax:
Practice Address - Street 1:2965 N PIERCE ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2553
Practice Address - Country:US
Practice Address - Phone:414-263-1579
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29180164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39989100Medicaid