Basic Information
| Provider Information | |||||||||
| NPI: | 1265666093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIR | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 S. NATIONAL AVE | ||||||||
| Address2: | STE. 540 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172692490 | ||||||||
| FaxNumber: | 4172692492 | ||||||||
| Practice Location | |||||||||
| Address1: | 816 E. MAIN | ||||||||
| Address2: | |||||||||
| City: | WILLOW SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657931597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172692490 | ||||||||
| FaxNumber: | 4172692492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 12/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 154917 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 26-8535 | 01 | MO | RH MEDICARE | OTHER | 1265666093 | 05 | MO | MEDICAID | 26D0889777 | 01 | MO | CLIA | OTHER | 597780303 | 01 | MO | RH MEDICAID | OTHER |