Provider Demographics
NPI:1194293043
Name:WILSON, BROOKE (AGACNP)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:MS
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:LARNED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AGACNP
Mailing Address - Street 1:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:485 S DOBSON RD STE 101
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5603
Practice Address - Country:US
Practice Address - Phone:480-728-4981
Practice Address - Fax:480-728-4985
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ220075363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care