Provider Demographics
NPI:1649965799
Name:ATILANO, BROOKE NYCOLE
Entity type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:NYCOLE
Last Name:ATILANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 NUGGET AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-9456
Mailing Address - Country:US
Mailing Address - Phone:760-463-5027
Mailing Address - Fax:760-379-5332
Practice Address - Street 1:2731 NUGGET AVE
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-9456
Practice Address - Country:US
Practice Address - Phone:760-463-5027
Practice Address - Fax:760-379-5332
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5170094172V00000X
175T00000X
CAMPSS-DXFPLC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker