MEDICARE: BROOKE ANN MACTAGGART CPNP-PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	C176768	IA

General Provider Information

NPI Number	:	1194507954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE ANN MACTAGGART CPNP-PC

Provider Business Mailing Address
First Line	:	715 ANDERSON ST
Second Line	:
City	:	MANCHESTER
State	:	IA
Zip	:	52057-1401
Country	:	US
Telephone Number	:	319-480-2540
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 E BUTLER ST
Second Line	:
City	:	MANCHESTER
State	:	IA
Zip	:	52057-1606
Country	:	US
Telephone Number	:	563-927-9400
Fax Number	:	563-927-6224

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2023
Last Update Date	:	03/29/2024

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