Provider Demographics
NPI:1144004268
Name:MATTOX, BROOKE LYNN
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LYNN
Last Name:MATTOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:HURT
Mailing Address - State:VA
Mailing Address - Zip Code:24563-2120
Mailing Address - Country:US
Mailing Address - Phone:951-207-3750
Mailing Address - Fax:
Practice Address - Street 1:2410 ATHERHOLT RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2148
Practice Address - Country:US
Practice Address - Phone:434-200-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009749363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant