Provider Demographics
NPI:1023525128
Name:BROOKS, LATHEA
Entity type:Individual
Prefix:
First Name:LATHEA
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 1:6010 W CALUMET RD APT 104
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-4127
Mailing Address - Country:US
Mailing Address - Phone:414-202-7465
Mailing Address - Fax:414-446-9916
Practice Address - Street 1:6010 W CALUMET RD APT 104
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-4127
Practice Address - Country:US
Practice Address - Phone:414-202-7465
Practice Address - Fax:414-446-9916
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIB6205249184602343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI464796343OtherDEPT. OF REVENUE