Healthcare Provider Details

I. General information

NPI: 1851114201
Provider Name (Legal Business Name): BROOKE NICOLE NOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 BRIDGE ST
DEDHAM MA
02026-1758
US

IV. Provider business mailing address

118 BRIDGE ST APT 301
DEDHAM MA
02026-1758
US

V. Phone/Fax

Practice location:
  • Phone: 716-863-1915
  • Fax:
Mailing address:
  • Phone: 716-863-1915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2354305
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN2354305
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: