Healthcare Provider Details

I. General information

NPI: 1588755482
Provider Name (Legal Business Name): HAIDY M BROOKS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5885 GLENRIDGE DR STE 100
ATLANTA GA
30328-5572
US

IV. Provider business mailing address

55 WHITCHER STREET SUITE 350
MARIETTA GA
30060-1129
US

V. Phone/Fax

Practice location:
  • Phone: 188-890-8055
  • Fax: 720-598-0440
Mailing address:
  • Phone: 770-424-6893
  • Fax: 770-424-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004751
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: