Healthcare Provider Details

I. General information

NPI: 1669242574
Provider Name (Legal Business Name): BROOKE WHITING LE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N MAIN AVE
GRESHAM OR
97030-7229
US

IV. Provider business mailing address

21960 NE CHINOOK WAY APT A
FAIRVIEW OR
97024-2627
US

V. Phone/Fax

Practice location:
  • Phone: 971-666-7795
  • Fax:
Mailing address:
  • Phone: 503-810-7202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberE-10238354
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberE-10238354
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: