Basic Information
| Provider Information | |||||||||
| NPI: | 1568801975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROZAK | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GIBSON-LAKE | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 141 COLUMBUS ROAD | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457011315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405924229 | ||||||||
| FaxNumber: | 7405924010 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 COLUMBUS ROAD | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457011315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405924229 | ||||||||
| FaxNumber: | 7405924010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.14576-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0086503 | 05 | OH | MEDICAID |