Provider Demographics
NPI:1801451554
Name:MACDOUGALL, BROOKE NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:MACDOUGALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4689
Mailing Address - Country:US
Mailing Address - Phone:309-674-7546
Mailing Address - Fax:309-282-2075
Practice Address - Street 1:1800 E 54TH ST STE B
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2852
Practice Address - Country:US
Practice Address - Phone:563-344-7546
Practice Address - Fax:563-344-1373
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA154405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily