=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720226228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE ANN BROOKER PMHNP, AGPCNP, BSN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2009
-----------------------------------------------------
Last Update Date | 10/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3134 WENDELL BLVD
-----------------------------------------------------
City | WENDELL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27591-7271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-374-7283
-----------------------------------------------------
Fax | 919-374-7285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3134 WENDELL BLVD
-----------------------------------------------------
City | WENDELL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27591-7271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-374-7285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 5006823
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 5006823
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------