Healthcare Provider Details

I. General information

NPI: 1346128568
Provider Name (Legal Business Name): BROOKE WADE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8341 PINOT GRIGIO ST
ROSEVILLE CA
95747-6680
US

IV. Provider business mailing address

8341 PINOT GRIGIO ST
ROSEVILLE CA
95747-6680
US

V. Phone/Fax

Practice location:
  • Phone: 916-990-5107
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number95263525
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: