Provider Demographics
NPI:1568987600
Name:MIDDLEBROOK, NICOLE (EMT-I)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MIDDLEBROOK
Suffix:
Gender:F
Credentials:EMT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30298-1132
Mailing Address - Country:US
Mailing Address - Phone:678-878-9834
Mailing Address - Fax:
Practice Address - Street 1:1174 FOREST PKWY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:GA
Practice Address - Zip Code:30260-3471
Practice Address - Country:US
Practice Address - Phone:678-878-9834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA146D00000X, 146M00000X
172A00000X, 372600000X
GA39499207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
No172A00000XOther Service ProvidersDriver
No372600000XNursing Service Related ProvidersAdult Companion