MEDICARE: BROGAN REPP

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	163W00000X	Registered Nurse	041413004	IL
2	363L00000X	Nurse Practitioner	209027936	IL

General Provider Information

NPI Number	:	1295431823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROGAN REPP

Provider Business Mailing Address
First Line	:	34159 N HAINESVILLE RD
Second Line	:
City	:	ROUND LAKE
State	:	IL
Zip	:	60073-9790
Country	:	US
Telephone Number	:	847-722-0063
Fax Number	:

Provider Business Practice Location Address
First Line	:	34159 N HAINESVILLE RD
Second Line	:
City	:	ROUND LAKE
State	:	IL
Zip	:	60073-9790
Country	:	US
Telephone Number	:	847-722-0063
Fax Number	:

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

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	01/05/2024

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Directions to “ BROGAN REPP ” Practice Location

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