Provider Demographics
NPI:1407325194
Name:VANDEPOLDER, BROOKE NICOLE (MS, AT, ATC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:VANDEPOLDER
Suffix:
Gender:F
Credentials:MS, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3571 S CIRCLE DR APT 3C
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-6694
Mailing Address - Country:US
Mailing Address - Phone:616-801-3490
Mailing Address - Fax:
Practice Address - Street 1:828 E PLAINFIELD CT
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1835
Practice Address - Country:US
Practice Address - Phone:616-801-3490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-25
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
MI26010023512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program