Provider Demographics
NPI:1962525840
Name:BROOKS, MARY ANN (CNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:BROOKS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:MITZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN MEDICAL STAFF SERVICES
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6000
Mailing Address - Country:US
Mailing Address - Phone:605-719-7109
Mailing Address - Fax:605-719-1027
Practice Address - Street 1:353 FAIRMONT BLVD.
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-719-1000
Practice Address - Fax:605-719-1027
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000097363LN0000X
SDR014468363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCP000097OtherCNP LICENSE
SD9254066OtherDAKOTACARE
SD4993197OtherWELLMARK
SD6829310Medicaid
SDR014468OtherRN LICENSE