Provider Demographics
NPI:1154701688
Name:STUART, BROOKE ELISABETH (DOM)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELISABETH
Last Name:STUART
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5048
Mailing Address - Country:US
Mailing Address - Phone:407-341-6592
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAITLAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-8406
Practice Address - Country:US
Practice Address - Phone:407-341-6592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3616171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist