Provider Demographics
NPI:1720656747
Name:STICKLEN, BROOKE ALEXANDRIA (PA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALEXANDRIA
Last Name:STICKLEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ALEXANDRIA
Other - Last Name:TODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1760 NICHOLASVILLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1410
Mailing Address - Country:US
Mailing Address - Phone:859-899-7950
Mailing Address - Fax:859-260-5150
Practice Address - Street 1:1760 NICHOLASVILLE RD STE 101
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1410
Practice Address - Country:US
Practice Address - Phone:859-899-7950
Practice Address - Fax:859-260-5150
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2908363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100770220Medicaid