Healthcare Provider Details

I. General information

NPI: 1790400265
Provider Name (Legal Business Name): BROOKE ANNE NICHOLS CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 BETHEL RD
RUFFIN SC
29475-3967
US

IV. Provider business mailing address

2233 BETHEL RD
RUFFIN SC
29475-3967
US

V. Phone/Fax

Practice location:
  • Phone: 843-635-0083
  • Fax:
Mailing address:
  • Phone: 843-635-0083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number558222
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: