Healthcare Provider Details

I. General information

NPI: 1457917676
Provider Name (Legal Business Name): CRYSTAL JILL BROOKS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VA CTR
AUGUSTA ME
04330-6719
US

IV. Provider business mailing address

334 OLD STAGE RD
ARROWSIC ME
04530-7410
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-8411
  • Fax: 207-621-4834
Mailing address:
  • Phone: 207-449-8788
  • Fax: 207-621-4834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR056361
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: