Healthcare Provider Details

I. General information

NPI: 1356613400
Provider Name (Legal Business Name): BROOKE R MINERICK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 S STEPHENSON AVE
IRON MOUNTAIN MI
49801-3637
US

IV. Provider business mailing address

PO BOX 370
IRON MOUNTAIN MI
49801-0370
US

V. Phone/Fax

Practice location:
  • Phone: 906-776-5457
  • Fax: 906-776-5488
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704246967
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: