Healthcare Provider Details

I. General information

NPI: 1528308558
Provider Name (Legal Business Name): JESSE I BROOME CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2013
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2367
US

IV. Provider business mailing address

PO BOX 5157
VANCOUVER WA
98668-5157
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-2000
  • Fax:
Mailing address:
  • Phone: 360-828-5396
  • Fax: 360-828-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9310702
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60556936
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: