Provider Demographics
NPI:1649851734
Name:BROEKHUIS, NICHOLE (RN, BSN, CRNP)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:BROEKHUIS
Suffix:
Gender:F
Credentials:RN, BSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 COTTON GIN RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3557
Mailing Address - Country:US
Mailing Address - Phone:937-901-2777
Mailing Address - Fax:
Practice Address - Street 1:420 COTTON GIN RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3557
Practice Address - Country:US
Practice Address - Phone:937-901-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-185641163W00000X, 363LP0200X
OHRN.423570163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse