=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679114557
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE ADELE CERRA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2019
-----------------------------------------------------
Last Update Date | 10/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11350 MCCORMICK RD
-----------------------------------------------------
City | HUNT VALLEY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21031-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-353-5990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 38TH ST
-----------------------------------------------------
City | ALTOONA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16602-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-937-7748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | UO2427
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------