Healthcare Provider Details

I. General information

NPI: 1649851734
Provider Name (Legal Business Name): NICHOLE BROEKHUIS RN, BSN, CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 MIAMI CHAPEL RD
DAYTON OH
45417-4650
US

IV. Provider business mailing address

721 MIAMI CHAPEL RD
DAYTON OH
45417-4650
US

V. Phone/Fax

Practice location:
  • Phone: 937-281-6800
  • Fax:
Mailing address:
  • Phone: 937-901-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN.CNP0036317
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1-185641
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-185641
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.423570
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: