Healthcare Provider Details

I. General information

NPI: 1134854839
Provider Name (Legal Business Name): NICALA NOELL BROOKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LIBERTY HILL RD
LUMBERTON NC
28358-2446
US

IV. Provider business mailing address

5224 DEBUT AVE
HOPE MILLS NC
28348-7563
US

V. Phone/Fax

Practice location:
  • Phone: 910-739-3318
  • Fax:
Mailing address:
  • Phone: 505-720-3393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0010-13076
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: