Provider Demographics
NPI:1003267345
Name:BRUBAKER, NICOLE MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 DELANO ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-1400
Mailing Address - Country:US
Mailing Address - Phone:315-298-6564
Mailing Address - Fax:315-298-3968
Practice Address - Street 1:124 SALISBURY ST
Practice Address - Street 2:
Practice Address - City:SANDY CREEK
Practice Address - State:NY
Practice Address - Zip Code:13145-7706
Practice Address - Country:US
Practice Address - Phone:315-387-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33 340733363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04550890Medicaid