=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912880733
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKLYN AMIA BRISTOW CCMA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2025
-----------------------------------------------------
Last Update Date | 07/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1121 WORTHINGTON WOODS BLVD # 6126
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43085-1568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-963-6673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1121 WORTHINGTON WOODS BLVD # 6126
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43085-1568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number | F6L7Y6F8
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------