Healthcare Provider Details

I. General information

NPI: 1336604644
Provider Name (Legal Business Name): NICOLE BRAZG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

33 W ONTARIO ST APT 52F
CHICAGO IL
60654-7775
US

V. Phone/Fax

Practice location:
  • Phone: 425-445-1865
  • Fax:
Mailing address:
  • Phone: 425-445-1865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP60916521
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209018362
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60905606
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041465583
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: