Healthcare Provider Details

I. General information

NPI: 1265666093
Provider Name (Legal Business Name): BROOKE L. FAIR FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2009
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 E. MAIN
WILLOW SPRINGS MO
65793-1597
US

IV. Provider business mailing address

3800 S. NATIONAL AVE STE. 540
SPRINGFIELD MO
65807-5284
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-2490
  • Fax: 417-269-2492
Mailing address:
  • Phone: 417-269-2490
  • Fax: 417-269-2492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number154917
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: