Healthcare Provider Details

I. General information

NPI: 1669016259
Provider Name (Legal Business Name): PENNY RUTH BROOKS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-6000
US

IV. Provider business mailing address

1308 S STATE ST
BUNNELL FL
32110-7619
US

V. Phone/Fax

Practice location:
  • Phone: 904-429-0001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11004937
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: