Basic Information
| Provider Information | |||||||||
| NPI: | 1457792939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROKAW | ||||||||
| FirstName: | KAITLYN | ||||||||
| MiddleName: | FRANCES | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCOY | ||||||||
| OtherFirstName: | KAITLYN | ||||||||
| OtherMiddleName: | FRANCES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSN, FNP-BC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 326 NICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788100 | ||||||||
| FaxNumber: | 9788788537 | ||||||||
| Practice Location | |||||||||
| Address1: | 326 NICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014201914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788100 | ||||||||
| FaxNumber: | 9788788537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN2292936 | MA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | RN2292936 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | RN634919 | PA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 26NR16441600 | NJ | N | Nursing Service Providers | Registered Nurse | 163W00000X | L10042610 | DE | N | Nursing Service Providers | Registered Nurse | 163W00000X | 069276-21 | NH | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 069276-23 | NH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.