Healthcare Provider Details

I. General information

NPI: 1649632068
Provider Name (Legal Business Name): LORI BROOKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/20/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 6TH STREET FRONTAGE RD E STE A
SPRINGFIELD IL
62703-5194
US

IV. Provider business mailing address

1307 E MONROE ST
SPRINGFIELD IL
62703-1224
US

V. Phone/Fax

Practice location:
  • Phone: 217-529-5046
  • Fax:
Mailing address:
  • Phone: 217-553-2548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209014117
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209014117
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209014117
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: