Healthcare Provider Details

I. General information

NPI: 1477597680
Provider Name (Legal Business Name): KELLY LYNNE BROEKHOF BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 2104 MASSEY AVE NAVAL STATION MAYPORT
JACKSONVILLE FL
32222
US

IV. Provider business mailing address

644 ORISKANY ST
JACKSONVILLE FL
32227-1712
US

V. Phone/Fax

Practice location:
  • Phone: 904-270-4293
  • Fax:
Mailing address:
  • Phone: 904-372-9141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN 45281
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: