Provider Demographics
NPI:1376274001
Name:TOLKACZ, BROOKLYN ANN
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:ANN
Last Name:TOLKACZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:43630 HAYES RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3545
Practice Address - Country:US
Practice Address - Phone:586-323-4530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant