Provider Demographics
NPI:1023784881
Name:BRUSTKERN, NICOLE LORRAINE (DNP, FNP-C, CPNP)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LORRAINE
Last Name:BRUSTKERN
Suffix:
Gender:F
Credentials:DNP, FNP-C, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 VIA BUENA APT 13-308
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3630
Mailing Address - Country:US
Mailing Address - Phone:425-269-2369
Mailing Address - Fax:
Practice Address - Street 1:5726 LA JOLLA BLVD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7344
Practice Address - Country:US
Practice Address - Phone:425-269-2369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018143363LP2300X, 363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics