Provider Demographics
NPI:1962955807
Name:GELECKI, BROOKE (NP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:GELECKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N ROADRUNNER PKWY
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-7044
Mailing Address - Country:US
Mailing Address - Phone:575-556-6440
Mailing Address - Fax:755-566-4455
Practice Address - Street 1:150 N ROADRUNNER PKWY
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7044
Practice Address - Country:US
Practice Address - Phone:575-556-6440
Practice Address - Fax:575-556-6445
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03466363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56086717Medicaid
NE47068731749Medicaid
NE47068731712Medicaid
NE47068731734Medicaid
NE10026480100Medicaid
IA1962955807Medicaid
NE099099323Medicare PIN
NE47068731734Medicaid