Provider Demographics
NPI:1639623143
Name:BROCKINGTON, NICOLE (LPN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BROCKINGTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FARRAGUT ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14611-2812
Mailing Address - Country:US
Mailing Address - Phone:585-285-8602
Mailing Address - Fax:
Practice Address - Street 1:100 FARRAGUT ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-2812
Practice Address - Country:US
Practice Address - Phone:585-285-8602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320355-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse