=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457728644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANESSA BROOKS DPT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2015
-----------------------------------------------------
Last Update Date | 07/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 MOONEY STREET
-----------------------------------------------------
City | WINSTON-SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-713-6038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 MOONEY STREET
-----------------------------------------------------
City | WINSTON-SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 146N00000X
-----------------------------------------------------
Taxonomy Name | Basic Emergency Medical Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | P17407
-----------------------------------------------------
License Number State |
-----------------------------------------------------