Healthcare Provider Details

I. General information

NPI: 1417100868
Provider Name (Legal Business Name): BROOKE KIVITZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 EUBANK BLVD NE
ALBUQUERQUE NM
87112-4166
US

IV. Provider business mailing address

9249 EVANGELINE AVE NE
ALBUQUERQUE NM
87111-2454
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-8806
  • Fax:
Mailing address:
  • Phone: 505-249-1056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2008-0036
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPA2008-0036
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: