Provider Demographics
NPI:1194184408
Name:CHILDERS, BROOKE B (NP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:B
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:B
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:35 W CHURCH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-1618
Mailing Address - Country:US
Mailing Address - Phone:706-253-2828
Mailing Address - Fax:706-253-2829
Practice Address - Street 1:220 J L WHITE DR STE 120
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4894
Practice Address - Country:US
Practice Address - Phone:706-692-3539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN161833363LA2200X, 363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health