MEDICARE: CINDY BROOKY I

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	164W00000X	Licensed Practical Nurse	PN.100326	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578779815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CINDY BROOKY I

Provider Business Mailing Address
First Line	:	1399 COUNTY ROAD 658
Second Line	:
City	:	NOVA
State	:	OH
Zip	:	44859-9741
Country	:	US
Telephone Number	:	419-962-4625
Fax Number	:

Provider Business Practice Location Address
First Line	:	1399 COUNTY ROAD 658
Second Line	:
City	:	NOVA
State	:	OH
Zip	:	44859-9741
Country	:	US
Telephone Number	:	419-962-4625
Fax Number	:

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

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	07/09/2007

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Directions to “ CINDY BROOKY I ” Practice Location

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