Provider Demographics
NPI:1285258855
Name:BRICKEY, DOUG J (DNP CRNA)
Entity type:Individual
Prefix:
First Name:DOUG
Middle Name:J
Last Name:BRICKEY
Suffix:
Gender:M
Credentials:DNP CRNA
Other - Prefix:
Other - First Name:DOUGLAS
Other - Middle Name:J
Other - Last Name:BRICKEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DNP CRNA
Mailing Address - Street 1:913 N MAIN ST APT 502
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-7058
Mailing Address - Country:US
Mailing Address - Phone:815-299-1090
Mailing Address - Fax:
Practice Address - Street 1:913 N MAIN ST APT 502
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-7058
Practice Address - Country:US
Practice Address - Phone:815-299-1090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-30
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041417502367500000X
IL209-021401367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered