Healthcare Provider Details

I. General information

NPI: 1033771563
Provider Name (Legal Business Name): BROOKE WACKER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2019
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1572 CITRUS MEDICAL CT
OCOEE FL
34761-4547
US

IV. Provider business mailing address

3835 N FREEWAY BLVD STE 100
SACRAMENTO CA
95834-1954
US

V. Phone/Fax

Practice location:
  • Phone: 855-501-1004
  • Fax: 866-456-9587
Mailing address:
  • Phone: 916-576-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11003575
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: