Provider Demographics
NPI:1003055492
Name:GUM, BROOKE (APRN)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:GUM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:SLATER, MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:66 CLUB RD STE 210
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2599
Mailing Address - Country:US
Mailing Address - Phone:541-972-4832
Mailing Address - Fax:541-393-5984
Practice Address - Street 1:66 CLUB RD STE 210
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2599
Practice Address - Country:US
Practice Address - Phone:541-972-4832
Practice Address - Fax:541-393-5984
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN128078163W00000X
WARN00157565163W00000X
OR10033180163W00000X, 363LP0808X
WAAP60074110363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse