Provider Demographics
NPI:1013902741
Name:BROERMAN, NICOLE STACK (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:STACK
Last Name:BROERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:STACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31310-0919
Mailing Address - Country:US
Mailing Address - Phone:912-369-9400
Mailing Address - Fax:
Practice Address - Street 1:462 ELMA G MILES PKWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4000
Practice Address - Country:US
Practice Address - Phone:912-369-9400
Practice Address - Fax:912-877-9438
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA47265208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT74835Medicaid
SCG98426Medicare UPIN