Basic Information
Provider Information | |||||||||
NPI: | 1154558534 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRIFFITH | ||||||||
FirstName: | BROOKE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUTLER | ||||||||
OtherFirstName: | BROOKE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2411 FOUNTAIN VIEW DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770574817 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7136204000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6720 BERTNER AVE | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770302604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8323552666 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2009 | ||||||||
LastUpdateDate: | 10/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 693446 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | AP117935 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 208723102 | 05 | TX |   | MEDICAID | 208723101 | 05 | TX |   | MEDICAID | P00834479 | 01 | TX | RAILROAD MEDICARE | OTHER | 8354UU | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |