Healthcare Provider Details

I. General information

NPI: 1043940018
Provider Name (Legal Business Name): BROOKE MADDIE PRYOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

7124 BRYNHURST DR
CHARLOTTE NC
28210-6500
US

V. Phone/Fax

Practice location:
  • Phone: 704-989-3723
  • Fax:
Mailing address:
  • Phone: 704-989-3723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number331170
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: