Provider Demographics
NPI:1144548744
Name:BROOME, BRENT FONDSHAY (CNA)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:FONDSHAY
Last Name:BROOME
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 DAVID PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:MOSELLE
Mailing Address - State:MS
Mailing Address - Zip Code:39459-9439
Mailing Address - Country:US
Mailing Address - Phone:601-596-3786
Mailing Address - Fax:
Practice Address - Street 1:6 DAVID PATTERSON RD
Practice Address - Street 2:
Practice Address - City:MOSELLE
Practice Address - State:MS
Practice Address - Zip Code:39459
Practice Address - Country:US
Practice Address - Phone:601-596-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA034616311ZA0620X, 376K00000X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No376K00000XNursing Service Related ProvidersNurse's Aide