Provider Demographics
NPI:1982274593
Name:VANCOPPENOLLE, BROOKE MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MICHELLE
Last Name:VANCOPPENOLLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MINONK
Mailing Address - State:IL
Mailing Address - Zip Code:61760-1425
Mailing Address - Country:US
Mailing Address - Phone:815-579-4093
Mailing Address - Fax:
Practice Address - Street 1:707 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MINONK
Practice Address - State:IL
Practice Address - Zip Code:61760-1425
Practice Address - Country:US
Practice Address - Phone:815-579-4093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041316088163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health