Provider Demographics
NPI:1659048015
Name:FIEDELMAN, BROOKE (APRN)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:FIEDELMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 N MOZART ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2718
Mailing Address - Country:US
Mailing Address - Phone:224-848-9629
Mailing Address - Fax:
Practice Address - Street 1:3134 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4414
Practice Address - Country:US
Practice Address - Phone:312-766-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041414299163W00000X
IL209.022770363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse