Healthcare Provider Details

I. General information

NPI: 1982281945
Provider Name (Legal Business Name): BROGHAN KAYLYNNE GASSER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S JACKSON ST
LOUISVILLE KY
40202-1675
US

IV. Provider business mailing address

4212 SEAGRAPE RD
LOUISVILLE KY
40299-4084
US

V. Phone/Fax

Practice location:
  • Phone: 502-562-3000
  • Fax:
Mailing address:
  • Phone: 313-520-5488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number1160536
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: