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General NPI Number Information
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NPI Number | 1932983137
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Entity Type | Individual
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Provider Name | BROOKE JENNA ROSE PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/21/2023
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Last Update Date | 10/28/2024
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Provider Practice Location Address
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Address Line | 1450 FERN CREEK DR
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City | STATESVILLE
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State | NC
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Zip | 28625-9376
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Country | US
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Telephone | 424-070-4237
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Fax |
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Provider Business Mailing Address
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Address Line | 170 MEDICAL PARK RD STE 208
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City | MOORESVILLE
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State | NC
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Zip | 28117-8541
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Country | US
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Telephone | 704-237-4240
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0010-13641
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License Number State | NC
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