Provider Demographics
NPI:1447014253
Name:WILL, BROOKE (LMT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WILL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:WILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:3254 GAY RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7613
Mailing Address - Country:US
Mailing Address - Phone:904-207-1388
Mailing Address - Fax:
Practice Address - Street 1:673 KINGSLEY AVE STE A
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5480
Practice Address - Country:US
Practice Address - Phone:904-207-1388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA100107225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist