Provider Demographics
NPI:1073190351
Name:SMITH, BROOKE NICOLE DOROTHY
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE DOROTHY
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:NICOLE
Other - Last Name:HEATWOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26 HOSPITAL DRIVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701
Mailing Address - Country:US
Mailing Address - Phone:740-249-4122
Mailing Address - Fax:
Practice Address - Street 1:191 W UNION ST STE 127
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2732
Practice Address - Country:US
Practice Address - Phone:740-592-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.017127207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine