Provider Demographics
NPI:1942748876
Name:BROOKS, WILLIAM (LVN)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29800 GLYNN LEE CT
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-9523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29800 GLYNN LEE CT
Practice Address - Street 2:
Practice Address - City:NEW HUDSON
Practice Address - State:MI
Practice Address - Zip Code:48165-9523
Practice Address - Country:US
Practice Address - Phone:248-862-4898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-12
Last Update Date:2017-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703117205164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703117205Medicaid