Healthcare Provider Details

I. General information

NPI: 1720790157
Provider Name (Legal Business Name): BROOKE MCKENNA RIES NP, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 30TH ST
LOS ANGELES CA
90007-3320
US

IV. Provider business mailing address

400 W 30TH ST
LOS ANGELES CA
90007-3320
US

V. Phone/Fax

Practice location:
  • Phone: 213-284-3200
  • Fax:
Mailing address:
  • Phone: 213-284-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95022708
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number236307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: