Healthcare Provider Details

I. General information

NPI: 1417362351
Provider Name (Legal Business Name): NICOLE BRASE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE ROBERTSON

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 RIDGE ST
IOWA CITY IA
52240-2720
US

IV. Provider business mailing address

PO BOX 824246
PHILADELPHIA PA
19182-4246
US

V. Phone/Fax

Practice location:
  • Phone: 217-370-3762
  • Fax:
Mailing address:
  • Phone: 850-985-9180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number137399
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209028100
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: