Basic Information
| Provider Information | |||||||||
| NPI: | 1033754122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREEDLOVE | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | ROCKAFELLOW | ||||||||
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| Credential: | MSN, RN, CPNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9796913300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 706 AVENUE G | ||||||||
| Address2: | |||||||||
| City: | MARBLE FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786545866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302018900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2019 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | AP143649 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.