Healthcare Provider Details

I. General information

NPI: 1932983137
Provider Name (Legal Business Name): BROOKE JENNA ROSE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 10/28/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 FERN CREEK DR
STATESVILLE NC
28625-9376
US

IV. Provider business mailing address

170 MEDICAL PARK RD STE 208
MOORESVILLE NC
28117-8541
US

V. Phone/Fax

Practice location:
  • Phone: 424-070-4237
  • Fax:
Mailing address:
  • Phone: 704-237-4240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-13641
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: