Provider Demographics
NPI:1952398729
Name:BROOK, SAGE E (CNM)
Entity Type:Individual
Prefix:
First Name:SAGE
Middle Name:E
Last Name:BROOK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601067
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1067
Mailing Address - Country:US
Mailing Address - Phone:704-512-5100
Mailing Address - Fax:704-512-5101
Practice Address - Street 1:325 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2535
Practice Address - Country:US
Practice Address - Phone:704-973-2106
Practice Address - Fax:704-973-2395
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC126103174400000X, 367A00000X
NC123103367A00000X
NC104367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1952398729Medicaid
NC104OtherNC CNM
NC7002111Medicaid
NC126103OtherRN LICENSE
SCMW0167Medicaid
SCMW0167Medicaid