Basic Information
| Provider Information | |||||||||
| NPI: | 1598032724 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLESPIE | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLMAN | ||||||||
| OtherFirstName: | BROOKE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5053 WOOSTER RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452262326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137512145 | ||||||||
| FaxNumber: | 5137512138 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 IVY GTWY STE 1100 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452451898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137512273 | ||||||||
| FaxNumber: | 5137511840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3007234 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 12831 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201132030 | 05 | IN | MEDICAID | 7100219870 | 05 | KY | MEDICAID | 0066512 | 05 | OH | MEDICAID |