Provider Demographics
NPI:1609609486
Name:TRUNNELLE, BROOKE NICOLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:TRUNNELLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8379 WHIRLAWAY ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-1322
Mailing Address - Country:US
Mailing Address - Phone:909-921-5906
Mailing Address - Fax:
Practice Address - Street 1:201 BULIFANTS BLVD STE B
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5731
Practice Address - Country:US
Practice Address - Phone:757-792-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
VA2305216748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist