Provider Demographics
NPI:1639751092
Name:BREKKE, NISSA K
Entity type:Individual
Prefix:
First Name:NISSA
Middle Name:K
Last Name:BREKKE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 E EVESHAM RD STE 101
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-1557
Mailing Address - Country:US
Mailing Address - Phone:856-325-3737
Mailing Address - Fax:
Practice Address - Street 1:121 LIBERTY WAY
Practice Address - Street 2:
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-6851
Practice Address - Country:US
Practice Address - Phone:320-583-1108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJP22-00457207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology