Provider Demographics
NPI:1023259017
Name:NITTA, BROOKE MIYOKO (PTA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:MIYOKO
Last Name:NITTA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 S PIONEER WAY
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2458
Mailing Address - Country:US
Mailing Address - Phone:509-765-1856
Mailing Address - Fax:509-765-3323
Practice Address - Street 1:1417 S PIONEER WAY
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2458
Practice Address - Country:US
Practice Address - Phone:509-765-1856
Practice Address - Fax:509-765-3323
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160045839225200000X
CA8702225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant