Healthcare Provider Details

I. General information

NPI: 1730916164
Provider Name (Legal Business Name): BROOKE NELLER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 NEWELL RD STE E31
BRISTOL CT
06010-5140
US

IV. Provider business mailing address

51 CROSSMAN RD
GOSHEN CT
06756-2117
US

V. Phone/Fax

Practice location:
  • Phone: 860-308-1020
  • Fax: 860-308-1024
Mailing address:
  • Phone: 860-912-0610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14930
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number174201
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: