Provider Demographics
NPI:1174090039
Name:BROOKS, DERIONNE
Entity type:Individual
Prefix:
First Name:DERIONNE
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 1:407 BEAUREGARD CIR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:972 HATHORN ROAD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:504-496-1361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT07422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer