Healthcare Provider Details

I. General information

NPI: 1720749864
Provider Name (Legal Business Name): BROOKE ALLISON DEVORE KENNEDY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 MATTLIND WAY
MILFORD DE
19963-5300
US

IV. Provider business mailing address

640 S STATE ST # MC3055
DOVER DE
19901-3530
US

V. Phone/Fax

Practice location:
  • Phone: 24-240-6003
  • Fax: 302-422-6214
Mailing address:
  • Phone: 302-480-1688
  • Fax: 302-480-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0011876
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: