MEDICARE: MRS. BROOKE LYNNE SUKHANOV CLD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374J00000X	Doula	13068072	GA

General Provider Information

NPI Number	:	1013256783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BROOKE LYNNE SUKHANOV CLD

Provider Business Mailing Address
First Line	:	1355 VILLAGE OAKS CIR APT 4
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312
Country	:	US
Telephone Number	:	423-716-3616
Fax Number	:

Provider Business Practice Location Address
First Line	:	1355 VILLAGE OAKS CIR APT 4
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312
Country	:	US
Telephone Number	:	423-716-3616
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2013
Last Update Date	:	01/31/2013

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