1225859267 NPI number — KEELY MICHELLE BROZ NP

Table of content: KEELY MICHELLE BROZ NP (NPI 1225859267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225859267 NPI number — KEELY MICHELLE BROZ NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROZ
Provider First Name:
KEELY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARRIS
Provider Other First Name:
KEELY
Provider Other Middle Name:
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:
1225859267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4007A ANDREWS LN # A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MC GUIRE AFB
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08641-1116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-637-3195
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 TRENTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNS MILLS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08015-1764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-893-1200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2024

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: 363L00000X , with the licence number:  26NJ15184000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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