Healthcare Provider Details

I. General information

NPI: 1003055492
Provider Name (Legal Business Name): BROOKE GUM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BROOKE SLATER, MONTGOMERY

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 CLUB RD STE 210
EUGENE OR
97401-2599
US

IV. Provider business mailing address

66 CLUB RD STE 210
EUGENE OR
97401-2599
US

V. Phone/Fax

Practice location:
  • Phone: 541-972-4832
  • Fax: 541-393-5984
Mailing address:
  • Phone: 541-972-4832
  • Fax: 541-393-5984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN128078
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00157565
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10033180
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60074110
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10033180
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: