Provider Demographics
NPI:1124877402
Name:BLAKEY, BROOKE R
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:R
Last Name:BLAKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 JEROME ST APT D
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-1463
Mailing Address - Country:US
Mailing Address - Phone:973-517-8079
Mailing Address - Fax:
Practice Address - Street 1:400 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1621
Practice Address - Country:US
Practice Address - Phone:908-677-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15022100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily