=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831764588
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIGAIL RAE BROCKHOUSE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2021
-----------------------------------------------------
Last Update Date | 08/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 WARHAWK WAY
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71209-2715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-342-3565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 609 BOND ST APT A14
-----------------------------------------------------
City | RUSTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71270-4979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-689-5016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 328489
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------