Healthcare Provider Details

I. General information

NPI: 1760972111
Provider Name (Legal Business Name): BROOKE SHELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3590 LUCILLE DR
CINCINNATI OH
45213
US

IV. Provider business mailing address

PO BOX 636256
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-4194
  • Fax:
Mailing address:
  • Phone: 513-245-3600
  • Fax: 513-245-3672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLE-00023030
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRNCNP022827
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: