Healthcare Provider Details

I. General information

NPI: 1093203465
Provider Name (Legal Business Name): BROOKE ANNE BOCCACCIO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 BUFORD HWY NE STE 100
BROOKHAVEN GA
30329-2146
US

IV. Provider business mailing address

2801 BUFORD HWY NE STE 100
BROOKHAVEN GA
30329-2146
US

V. Phone/Fax

Practice location:
  • Phone: 678-820-7830
  • Fax: 678-373-0339
Mailing address:
  • Phone: 678-820-7830
  • Fax: 678-373-0339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN224129
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP224129
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: