Healthcare Provider Details

I. General information

NPI: 1780560250
Provider Name (Legal Business Name): BROOKE HAVEN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3632 SHAMROCK W STE 3
TALLAHASSEE FL
32309-2686
US

IV. Provider business mailing address

PO BOX 135
HAVANA FL
32333-0135
US

V. Phone/Fax

Practice location:
  • Phone: 850-273-5979
  • Fax: 850-792-1312
Mailing address:
  • Phone: 850-273-5979
  • Fax: 850-792-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KRISTI BROOKE CONOLY
Title or Position: CEO
Credential: APRN, PMHNP-BC
Phone: 229-400-2625