Provider Demographics
NPI:1952971590
Name:BROOKS, ELISSA MARIE (ACNP)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:MARIE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3692 HEATHER AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-3835
Mailing Address - Country:US
Mailing Address - Phone:928-303-5634
Mailing Address - Fax:
Practice Address - Street 1:3269 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3619
Practice Address - Country:US
Practice Address - Phone:928-757-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-27
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ259148363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine