Healthcare Provider Details

I. General information

NPI: 1568801975
Provider Name (Legal Business Name): KIMBERLY ANN BROZAK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY ANN GIBSON-LAKE

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CHARLES ST
ATHENS OH
45701-2329
US

IV. Provider business mailing address

5 CHARLES ST
ATHENS OH
45701-2329
US

V. Phone/Fax

Practice location:
  • Phone: 855-472-4633
  • Fax: 740-447-9016
Mailing address:
  • Phone: 855-472-4633
  • Fax: 740-447-9016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.14576-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: