1073190351 NPI number — BROOKE NICOLE DOROTHY SMITH DO

Table of content: BROOKE NICOLE DOROTHY SMITH DO (NPI 1073190351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073190351 NPI number — BROOKE NICOLE DOROTHY SMITH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
BROOKE
Provider Middle Name:
NICOLE DOROTHY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEATWOLE
Provider Other First Name:
BROOKE
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073190351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THORNVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43076-0011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-263-7170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
THORNVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-263-7170
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34.017127 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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