Provider Demographics
NPI:1407325194
Name:VANDEPOLDER, BROOKE NICOLE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:VANDEPOLDER
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 1:828 E PLAINFIELD CT
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1835
Mailing Address - Country:US
Mailing Address - Phone:616-801-3490
Mailing Address - Fax:
Practice Address - Street 1:828 E PLAINFIELD CT
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1835
Practice Address - Country:US
Practice Address - Phone:616-801-3490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-25
Last Update Date:2018-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program