Provider Demographics
NPI:1871261842
Name:FREDERICK-BACA, BROOKE LAUREN (DNP, PMHNP, RN)
Entity type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:LAUREN
Last Name:FREDERICK-BACA
Suffix:
Gender:F
Credentials:DNP, PMHNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4764 E SUNRISE DR # 1038
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-4535
Mailing Address - Country:US
Mailing Address - Phone:520-703-6415
Mailing Address - Fax:
Practice Address - Street 1:4764 E SUNRISE DR # 1038
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-4535
Practice Address - Country:US
Practice Address - Phone:520-703-6415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ242311163WP0807X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & AdolescentGroup - Single Specialty