Provider Demographics
NPI:1366063539
Name:BALL, BROOKE (CNA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BALL
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 CONSTITUTION DR SW # B
Mailing Address - Street 2:
Mailing Address - City:POPLAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61065-8729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 CONSTITUTION DR SW # B
Practice Address - Street 2:
Practice Address - City:POPLAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:61065-8729
Practice Address - Country:US
Practice Address - Phone:815-355-5369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE