1770177503 NPI number — MISS KIALEIGH ANTIONETTE BROOKS

Table of content: MISS KIALEIGH ANTIONETTE BROOKS (NPI 1770177503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770177503 NPI number — MISS KIALEIGH ANTIONETTE BROOKS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
KIALEIGH
Provider Middle Name:
ANTIONETTE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770177503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10310 7TH REGIMENT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANASSAS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20110-6765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10370 BATTLEVIEW PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20109-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-364-0440
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2021

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: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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