Healthcare Provider Details

I. General information

NPI: 1275075152
Provider Name (Legal Business Name): MICHAEL P. BROCKMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5348 LAMME RD
MORAINE OH
45439-3215
US

IV. Provider business mailing address

5348 LAMME RD
MORAINE OH
45439-3215
US

V. Phone/Fax

Practice location:
  • Phone: 937-534-4651
  • Fax: 937-522-8799
Mailing address:
  • Phone: 937-534-4651
  • Fax: 937-522-8799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.024158
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: