1952784209 NPI number — COURTNEY BROOKS FNP

Table of content: STANTON L LONGENECKER MD (NPI 1821092271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952784209 NPI number — COURTNEY BROOKS FNP

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAVES-SUTTON
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1952784209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 FAMILY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71006-9320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-355-8176
Provider Business Mailing Address Fax Number:
817-761-7132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 FAMILY CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71006-9320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-355-8176
Provider Business Practice Location Address Fax Number:
817-761-7132
Provider Enumeration Date:
07/06/2015

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: 363LF0000X , with the licence number:  AP08339 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2408372 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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