Provider Demographics
NPI:1053876573
Name:THOUVENOT, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:THOUVENOT
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 1:715 SOUTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-9021
Mailing Address - Country:US
Mailing Address - Phone:785-209-3779
Mailing Address - Fax:785-209-3780
Practice Address - Street 1:842 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:KS
Practice Address - Zip Code:66043-1305
Practice Address - Country:US
Practice Address - Phone:913-250-5155
Practice Address - Fax:913-250-5515
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009026463163WP0808X
KS14-133740-051163WP0808X
MO2019004291363LP0808X
KS53-80720-051363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3005123750001Medicaid