Provider Demographics
NPI:1124912332
Name:CHILD, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:CHILD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3234 W CAMERON CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-3024
Mailing Address - Country:US
Mailing Address - Phone:801-631-0720
Mailing Address - Fax:
Practice Address - Street 1:3234 W CAMERON CT
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3024
Practice Address - Country:US
Practice Address - Phone:801-631-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10968099-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner