Basic Information
Provider Information | |||||||||
NPI: | 1417049404 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROOKS-HALL | ||||||||
FirstName: | REGINA | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROOKS | ||||||||
OtherFirstName: | REGINA | ||||||||
OtherMiddleName: | MARY | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 635283 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452635283 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593012000 | ||||||||
FaxNumber: | 8594264140 | ||||||||
Practice Location | |||||||||
Address1: | 711 MEDICAL VILLAGE DR | ||||||||
Address2: |   | ||||||||
City: | EDGEWOOD | ||||||||
State: | KY | ||||||||
PostalCode: | 410173439 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593310774 | ||||||||
FaxNumber: | 8595783800 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2006 | ||||||||
LastUpdateDate: | 01/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001168260 | VA | N |   | Nursing Service Providers | Registered Nurse |   | 363L00000X | 0017138054 | VA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | 3006374 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 3159844 | 05 | OH |   | MEDICAID | 7100163060 | 05 | KY |   | MEDICAID |