Provider Demographics
NPI:1912880733
Name:BRISTOW, BROOKLYN AMIA (CCMA)
Entity type:Individual
Prefix:MISS
First Name:BROOKLYN
Middle Name:AMIA
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 WORTHINGTON WOODS BLVD # 6126
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-1568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1121 WORTHINGTON WOODS BLVD # 6126
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-1568
Practice Address - Country:US
Practice Address - Phone:740-963-6673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF6L7Y6F83747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant