Provider Demographics
NPI:1942441423
Name:NICHOLS, BROOKE E (NP-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:E
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:E
Other - Last Name:THIELKING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1255 THEATRE DR
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-3772
Mailing Address - Country:US
Mailing Address - Phone:641-451-0382
Mailing Address - Fax:
Practice Address - Street 1:1255 THEATRE DR
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-3772
Practice Address - Country:US
Practice Address - Phone:641-451-0382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-13
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46327363LF0000X
MO2004018377363LF0000X
IAA110227363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00708246OtherRAILROAD MEDICARE MO
MO1942441423Medicaid
MO3054094OtherUNITED HEALTHCARE
MO43341011OtherBCBS OF KANSAS CITY
KSP00719486OtherRAILROAD MEDICARE KS
KSP00719486OtherRAILROAD MEDICARE KS
MO1942441423Medicaid
MO3054094OtherUNITED HEALTHCARE
MO43341011OtherBCBS OF KANSAS CITY