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General NPI Number Information
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NPI Number | 1720861206
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Entity Type | Individual
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Provider Name | EMILY BROOKE NULL PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/17/2023
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Last Update Date | 05/13/2025
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Provider Practice Location Address
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Address Line | 6665 IL-146 E
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City | VIENNA
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State | ID
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Zip | 62995-9998
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Country | US
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Telephone | 618-658-8331
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Fax |
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Provider Business Mailing Address
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Address Line | 6665 IL-146 E
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City | VIENNA
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State | IL
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Zip | 62995-9998
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085.009966
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License Number State | IL
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