MEDICARE: MRS. KELLY LYNNE BROEKHOF BSN

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	163WC0400X	Case Management Registered Nurse	RN 45281	HI

General Provider Information

NPI Number	:	1477597680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY LYNNE BROEKHOF BSN

Provider Business Mailing Address
First Line	:	644 ORISKANY ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32227-1712
Country	:	US
Telephone Number	:	904-372-9141
Fax Number	:

Provider Business Practice Location Address
First Line	:	BLDG 2104 MASSEY AVE
Second Line	:	NAVAL STATION MAYPORT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222
Country	:	US
Telephone Number	:	904-270-4293
Fax Number	:

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	07/08/2007

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