1568801975 NPI number — KIMBERLY ANN BROZAK NURSE PRACTITIONER

Table of content: KIMBERLY ANN BROZAK NURSE PRACTITIONER (NPI 1568801975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568801975 NPI number — KIMBERLY ANN BROZAK NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROZAK
Provider First Name:
KIMBERLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIBSON-LAKE
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568801975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 COLUMBUS ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45701-1315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-592-4229
Provider Business Mailing Address Fax Number:
740-592-4010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
141 COLUMBUS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45701-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-592-4229
Provider Business Practice Location Address Fax Number:
740-592-4010
Provider Enumeration Date:
06/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  COA.14576-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0086503 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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