Provider Demographics
NPI:1356371355
Name:BROOKER, NICOLE C (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:BROOKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:C
Other - Last Name:BREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:42 KIMBALL HILL RD
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:ME
Mailing Address - Zip Code:04020-3629
Mailing Address - Country:US
Mailing Address - Phone:207-299-5688
Mailing Address - Fax:
Practice Address - Street 1:840 HAMMOND ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4339
Practice Address - Country:US
Practice Address - Phone:207-433-7778
Practice Address - Fax:866-220-5031
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432258299Medicaid
ME0951Medicare PIN
MEVX1632Medicare PIN