MEDICARE: MS. EDEISHA E BROOKS APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN.373630	OH
2	363LF0000X	Family Nurse Practitioner	COA19041	OH

General Provider Information

NPI Number	:	1912126897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. EDEISHA E BROOKS APRN

Provider Business Mailing Address
First Line	:	4135 TUSCARAWAS ST W
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-5463
Country	:	US
Telephone Number	:	419-295-8811
Fax Number	:

Provider Business Practice Location Address
First Line	:	4135 TUSCARAWAS ST W
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-5463
Country	:	US
Telephone Number	:	419-612-1204
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	08/17/2016

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