Healthcare Provider Details

I. General information

NPI: 1033785860
Provider Name (Legal Business Name): BROOKE FANDRICH PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N ST STE 202
ROCK SPRINGS WY
82901-5474
US

IV. Provider business mailing address

2208 WEATHERBY AVE
ROCK SPRINGS WY
82901-6841
US

V. Phone/Fax

Practice location:
  • Phone: 307-630-3466
  • Fax:
Mailing address:
  • Phone: 307-212-1042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number49873
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number13074058-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: