MEDICARE: KAREN LYNNE BROOKS PCA

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	3747P1801X	Personal Care Attendant		WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3810020100	OTHER	WV	PROVIDER ID

General Provider Information

NPI Number	:	1801302260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN LYNNE BROOKS PCA

Provider Business Mailing Address
First Line	:	4807 B TENNESSEE STREET
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309
Country	:	US
Telephone Number	:	304-356-4562
Fax Number	:	304-558-4563

Provider Business Practice Location Address
First Line	:	4807-B TENNESSEE STREET
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	45309
Country	:	US
Telephone Number	:	304-356-4562
Fax Number	:	304-558-4563

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

Provider Enumeration Date	:	12/21/2017
Last Update Date	:	12/21/2017

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