Provider Demographics
NPI:1114462561
Name:BROKAW, SHANTELLE
Entity Type:Individual
Prefix:MRS
First Name:SHANTELLE
Middle Name:
Last Name:BROKAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06120-2508
Mailing Address - Country:US
Mailing Address - Phone:860-249-9625
Mailing Address - Fax:860-808-1580
Practice Address - Street 1:128 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-2700
Practice Address - Country:US
Practice Address - Phone:203-757-9271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6831363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health