Provider Demographics
NPI:1588062467
Name:BROOKS, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BROOKS
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 1:1105 E KENNEDY BLVD
Mailing Address - Street 2:MAIN BLDG
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602
Mailing Address - Country:US
Mailing Address - Phone:813-307-8064
Mailing Address - Fax:813-272-7116
Practice Address - Street 1:1105 E KENNEDY BLVD
Practice Address - Street 2:MAIN BLDG
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602
Practice Address - Country:US
Practice Address - Phone:813-307-8064
Practice Address - Fax:813-272-7116
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9295291363LF0000X
FLARNP9295291363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020125200Medicaid