Healthcare Provider Details

I. General information

NPI: 1467170472
Provider Name (Legal Business Name): NICOLE BROCKMAN PNP, MSN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 CLAYTON AVE
SAINT LOUIS MO
63110-1624
US

IV. Provider business mailing address

45 FOX MDWS
SAINT LOUIS MO
63127-1448
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-3600
  • Fax:
Mailing address:
  • Phone: 314-495-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2021009743
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: