Healthcare Provider Details

I. General information

NPI: 1790783207
Provider Name (Legal Business Name): SANDRA L BROOKS ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 N NOVA RD STE 203
ORMOND BEACH FL
32174-4422
US

IV. Provider business mailing address

533 N NOVA RD STE 203
ORMOND BEACH FL
32174-4422
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-7175
  • Fax: 386-672-0771
Mailing address:
  • Phone: 386-672-7175
  • Fax: 386-672-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2650922
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: