Provider Demographics
NPI:1982942355
Name:NISS, BROOKE STERLING (LAC)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:STERLING
Last Name:NISS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:STERLING
Other - Last Name:DORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:4209 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-3027
Mailing Address - Country:US
Mailing Address - Phone:323-617-5027
Mailing Address - Fax:323-617-5027
Practice Address - Street 1:4209 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-3027
Practice Address - Country:US
Practice Address - Phone:323-617-5027
Practice Address - Fax:323-617-5027
Is Sole Proprietor?:No
Enumeration Date:2013-01-19
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13958171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist