Provider Demographics
NPI:1720639263
Name:BROSSEAU, NICHOLETTE
Entity Type:Individual
Prefix:MRS
First Name:NICHOLETTE
Middle Name:
Last Name:BROSSEAU
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 1:5130 S HUDSON PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-7509
Mailing Address - Country:US
Mailing Address - Phone:918-704-7825
Mailing Address - Fax:
Practice Address - Street 1:1520 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4839
Practice Address - Country:US
Practice Address - Phone:918-704-7825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program