Provider Demographics
NPI:1992063135
Name:IWANSKI, BROOKE NICHOLE (DC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICHOLE
Last Name:IWANSKI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9101 W COLLEGE POINTE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3390
Mailing Address - Country:US
Mailing Address - Phone:239-208-0088
Mailing Address - Fax:239-288-0804
Practice Address - Street 1:9101 W COLLEGE POINTE DR STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3390
Practice Address - Country:US
Practice Address - Phone:239-208-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10604111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0193652102Medicaid