Provider Demographics
NPI:1326512187
Name:NICHOLSON, BROOKE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 BRIDGER DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8354
Mailing Address - Country:US
Mailing Address - Phone:406-399-1878
Mailing Address - Fax:
Practice Address - Street 1:7401 BRIDGER DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-8354
Practice Address - Country:US
Practice Address - Phone:406-399-1878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer