Provider Demographics
NPI:1891524120
Name:RALEY, BROOKE ALLISON
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALLISON
Last Name:RALEY
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:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-0106
Mailing Address - Country:US
Mailing Address - Phone:765-376-6628
Mailing Address - Fax:
Practice Address - Street 1:1716 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2173
Practice Address - Country:US
Practice Address - Phone:765-742-1567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015537A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health